Sucrose for analgesia in newborn infants undergoing painful procedures

Summary and Analysis of Relevant Evidence for Nondrug Nursing Programs in Neonatal Operational Pain Management

Purpose

To summarize the relevant evidence for nondrug nursing programs in neonatal operational pain management.

Methods

Computer search for the literature on neonatal procedural pain from 2015 to 2020 in Up To Date, JBI, NICE, SIGN, RNAO, NGC, PubMed, Cochrane Library, CNKI, and Wanfang database was conducted. All literature works that may meet the inclusion criteria were independently evaluated by two researchers to determine the quality grade of the articles.

Results

Finally, 9 literature works were extracted, including 4 guidelines, 3 systematic reviews, and 2 evidence summaries. The relevant contents of the literature were extracted and summarized, and 20 pieces of the best evidence were obtained.

Conclusion

Breast feeding, sweetener, Kangaroo mother care, sensory stimulation, nonnutritive sucking, and other nondrug nursing programs can reduce the neonatal operational pain, which has guiding significance in neonatal operational pain management.

Event-related potentials evoked by skin puncture reflect activation of Aβ fibers: comparison with intraepidermal and transcutaneous electrical stimulations

Background

Recently, event-related potentials (ERPs) evoked by skin puncture, commonly used for blood sampling, have received attention as a pain assessment tool in neonates. However, their latency appears to be far shorter than the latency of ERPs evoked by intraepidermal electrical stimulation (IES), which selectively activates nociceptive Aδ and C fibers. To clarify this important issue, we examined whether ERPs evoked by skin puncture appropriately reflect central nociceptive processing, as is the case with IES.

Methods

In Experiment 1, we recorded evoked potentials to the click sound produced by a lance device (click-only), lance stimulation with the click sound (click+lance), or lance stimulation with white noise (WN+lance) in eight healthy adults to investigate the effect of the click sound on the ERP evoked by skin puncture. In Experiment 2, we tested 18 heathy adults and recorded evoked potentials to shallow lance stimulation (SL) with a blade that did not reach the dermis (0.1 mm insertion depth); normal lance stimulation (CL) (1 mm depth); transcutaneous electrical stimulation (ES), which mainly activates Aβ fibers; and IES, which selectively activates Aδ fibers when low stimulation current intensities are applied. White noise was continuously presented during the experiments. The stimulations were applied to the hand dorsum. In the SL, the lance device did not touch the skin and the blade was inserted to a depth of 0.1 mm into the epidermis, where the free nerve endings of Aδ fibers are located, which minimized the tactile sensation caused by the device touching the skin and the activation of Aβ fibers by the blade reaching the dermis. In the CL, as in clinical use, the lance device touched the skin and the blade reached a depth of 1 mm from the skin surface, i.e., the depth of the dermis at which the Aβ fibers are located.

Results

The ERP N2 latencies for click-only (122 ± 2.9 ms) and click+lance (121 ± 6.5 ms) were significantly shorter than that for WN+lance (154 ± 7.1 ms). The ERP P2 latency for click-only (191 ± 11.3 ms) was significantly shorter than those for click+lance (249 ± 18.6 ms) and WN+lance (253 ± 11.2 ms). This suggests that the click sound shortens the N2 latency of the ERP evoked by skin puncture. The ERP N2 latencies for SL, CL, ES, and IES were 146 ± 8.3, 149 ± 9.9, 148 ± 13.1, and 197 ± 21.2 ms, respectively. The ERP P2 latencies were 250 ± 18.2, 251 ± 14.1, 237 ± 26.3, and 294 ± 30.0 ms, respectively. The ERP latency for SL was significantly shorter than that for IES and was similar to that for ES. This suggests that the penetration force generated by the blade of the lance device activates the Aβ fibers, consequently shortening the ERP latency.

Conclusions

Lance ERP may reflect the activation of Aβ fibers rather than Aδ fibers. A pain index that correctly and reliably reflects nociceptive processing must be developed to improve pain assessment and management in neonates.

A cluster randomized clinical trial to evaluate the effectiveness of the Implementation of Infant Pain Practice Change (ImPaC) Resource to improve pain practices in hospitalized infants: a study protocol

BACKGROUND

Hospitalized infants undergo multiple painful procedures daily. Despite the significant evidence, procedural pain assessment and management continues to be suboptimal. Repetitive and untreated pain at this vital developmental juncture is associated with negative behavioral and neurodevelopmental consequences. To address this knowledge to practice gap, we developed the web-based Implementation of Infant Pain Practice Change (ImPaC) Resource to guide change in healthcare professionals' pain practice behaviors. This protocol describes the evaluation of the intervention effectiveness and implementation of the Resource and how organizational context influences outcomes.

METHODS

An effectiveness-implementation hybrid type 1 design, blending a cluster randomized clinical trial and a mixed-methods implementation study will be used. Eighteen Neonatal Intensive Care Units (NICUs) across Canada will be randomized to intervention (INT) or standard practice (SP) groups. NICUs in the INT group will receive the Resource for six months; those in the SP group will continue with practice as usual and will be offered the Resource after a six-month waiting period. Data analysts will be blinded to group allocation. To address the intervention effectiveness, the INT and SP groups will be compared on clinical outcomes including the proportion of infants who have procedural pain assessed and managed, and the frequency and nature of painful procedures. Data will be collected at baseline (before randomization) and at completion of the intervention (six months). Implementation outcomes (feasibility, fidelity, implementation cost, and reach) will be measured at completion of the intervention. Sustainability will be assessed at six and 12 months following the intervention. Organizational context will be assessed to examine its influence on intervention and implementation outcomes.

DISCUSSION

This mixed-methods study aims to determine the effectiveness and the implementation of a multifaceted online strategy for changing healthcare professionals' pain practices for hospitalized infants. Implementation strategies that are easily and effectively implemented are important for sustained change. The results will inform healthcare professionals and decision-makers on how to address the challenges of implementing the Resource within various organizational contexts.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03825822. Registered 31 January 2019.

The Effects of Massage and Breastfeeding on Response to Venipuncture Pain among Hospitalized Neonates

BACKGROUND

Untreated procedural pain leads to long-term and short-term complications in neonates. Preventing pain in sick infants and neonates, whose conditions are getting worse, not only is a professional and legal duty but also a prevention measure to decrease future psychological and even neurological complications. Therefore, nurses should prevent newborns' pain. The aim of this study was to compare the effects of massage and breastfeeding on the pain of the neonates.

MATERIALS AND METHODS

This was a clinical trial conducted among 75 full-term and near-term infants who underwent venipuncture. The newborns were randomly allocated to the following groups (n = 25 for each): group 1, breastfeeding; group 2, massage; and group 3, control. In the first group, venipuncture was done 2 minutes after breastfeeding. In the second group, massage was done with effleurage technique for 3 minutes and venipuncture was done 2 minutes after massage. The Neonatal Infant Pain Scale (NIPS) was used for pain measurement in the first 30 seconds of venipuncture. Data were analyzed by t-test and one-way analysis of variance (ANOVA).

RESULTS

The lowest mean pain score recorded in the massage group (0.92) whereas it was 4.84 in the breastfeeding group and 6.16 in the control group. ANOVA test and post-hoc statistics revealed that both interventions resulted in a significant reduction of the pain scores.

CONCLUSIONS

According to the findings of this study, the lowest pain score was in massage group, then in breastfeeding group and control group accordingly. Considering the fact that massage and breastfeeding are natural, useful, and cost free interventions and do not need any special facility, these methods are suggested in pain management and pain control during painful procedures administrated for infants.

Effects of combined oral sucrose and nonnutritive sucking (NNS) on procedural pain of NICU newborns, 2001 to 2016: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Both oral sucrose (OS) and nonnutritive sucking (NNS) are effective nonpharmacological methods to alleviate procedures pain in neonatal intensive care unit (NICU) newborns when they were used alone, but the combined effect of OS+NNS remains controversial. So, we conducted this study to evaluate the efficiency of NNS combined with oral sucrose on pain relief in NICU newborns undergoing painful procedures.

METHODS

We searched PubMed, Ovid (Medline), Embase (Medline), Cochrane Central Library, and other resources such as Google Scholar, bibliographies of included literatures for all available articles. Two reviewers screened literatures and extracted data independently. The fixed effects model was used to pool the results using Reviewer Manager (RevMan) 5.3. As each study included in our meta-analysis had been approved by Ethics Committee or institutional review board, thus our study did not need ethical approval.

RESULTS

Seven randomized controlled trials, including 599 participants, were contained in our meta-analysis. The combination of oral sucrose and NNS is associated with reduced pain scores (mean difference [MD], -0.52; 95% confidence interval [CI], -0.68 to -0.36); shortened crying time (MD,-0.92; 95% CI, -1.39 to -0.44); but the 2 groups did not differ significantly in reducing bradycardia (MD, 0.73; 95% CI, 0.32-1.68), tachycardia (MD, 0.65; 95% CI, 0.38-1.10), or desaturations (MD, 0.73; 95% CI, 0.32-1.68).

CONCLUSION

The pooled evidence indicates that the combination measures may serve as an evidence-based guideline for pain relief among patients having minor pain. Besides, it also indicates that OS combined with NNS can be an alternative for better prevention and management of procedure pain in NICU newborns. Nevertheless, the results may be limited due to incomplete data, and thus, more randomized controlled trials or well-designed studies are required to determine the effects of OS+NNS in the future.

Beyond Acute Pain: Understanding Chronic Pain in Infancy

This topical review presents the current challenges in defining chronic pain in infants, summarizes evidence from animal and human infant studies regarding the biological processes necessary for chronic pain signaling, and presents observational/experiential evidence from clinical experts. A literature search of four databases (CINAHL, EMBASE, PsycINFO, and MEDLINE) was conducted, along with hand searches of reference lists. Evidence from animal studies suggest that important neurophysiological mechanisms, such as the availability of key neurotransmitters needed for maintenance of chronic pain, may be immature or absent in the developing neonate. In some cases, human infants may be significantly less likely to develop chronic pain. However, evidence also points to altered pain perception, such as allodynia and hyperalgesia, with significant injury. Moreover, clinicians and parents in pediatric intensive care settings describe groups of infants with altered behavioral responses to repeated or prolonged painful stimuli, yet agreement on a working definition of chronic pain in infancy remains elusive. While our understanding of infant chronic pain is still in the rudimentary stages, a promising avenue for the future assessment of chronic pain in infancy would be to develop a clinical tool that uses both neurophysiological approaches and clinical perceptions already presented in the literature.

Evolutionary and neuropsychological perspectives on addictive behaviors and addictive substances: relevance to the "food addiction" construct

It has been argued that food cannot be "addictive", unlike conventional drugs of abuse, because it is an essential part of life. In this paper, evidence is reviewed, largely from an evolutionary psychobiological perspective, that plant-based psychoactive drugs (such as those derived from the opium poppy and the coca leaf) and gambling-related behaviors were once adaptive for human health and survival in a similar manner as energy-based foods were for nourishment. "Evolutionary mismatch" viewpoints contend that certain behaviors were enhanced during the hunter-gatherer lifestyle - from which our genetic endowment had its origins - because they bestowed both survival and reproductive advantages to the species. However, in the context of advanced technology and other rapid environmental changes, these same behaviors have tended to become maladaptive and greatly overexpressed. Similar to the manufactured purification of psychotropic plant-based substances, the reward impact of processed and hyperpalatable foods, with their high levels of sugar, fat, and salt, is much increased from foods produced in nature. It is concluded therefore that what was once beneficial and necessary for our survival has been altered and ultraprocessed into edible products that may be disadvantageous and potentially addictive.

Toy-mediated distraction: clarifying the role of agent of distraction and preneedle distress in toddlers

BACKGROUND

Distraction has recently gained attention as a technique that may help reduce acute pain in infants and toddlers; however, results remain equivocal. It appears that these mixed results stem from a variety of methodological differences with regard to how distraction is implemented.

OBJECTIVES

To offer more definitive conclusions regarding the efficacy and mechanisms of distraction for pain management during infancy. Specifically, the goal was to examine whether the agent of distraction (i.e., the specific person conducting the distraction) and preneedle distress behaviours impact the efficacy of distraction when toddlers were held by parents.

METHODS

A total of 99 toddlers were randomly assigned to one of three conditions (typical care, research assistant-directed distraction or parent-directed distraction). Toddler distress behaviours were assessed pre- and postneedle. Toddlers were further grouped according to distress behaviours preneedle (low⁄no distress versus high distress). Parental soothing behaviours were also assessed as a manipulation check.

RESULTS

Toddler postneedle pain did not significantly differ among groups. However, toddlers who were distressed preneedle displayed significantly more pain postneedle, regardless of the treatment group. There were no significant interactions between treatment group and preneedle distress behaviours.

CONCLUSIONS

These results suggest that, when being held by a parent, distraction using a toy does not result in lower pain scores in the context of immunization, regardless of who offers the distraction. Furthermore, these findings raise the notion that if clinicians ensured toddlers were regulated before attempting an immunization, postneedle pain may be significantly reduced.

Oral sucrose for heel lance increases adenosine triphosphate use and oxidative stress in preterm neonates

OBJECTIVE

To examine the effects of sucrose on pain and biochemical markers of adenosine triphosphate (ATP) degradation and oxidative stress in preterm neonates experiencing a clinically required heel lance.

STUDY DESIGN

Preterm neonates that met study criteria (n = 131) were randomized into 3 groups: (1) control; (2) heel lance treated with placebo and non-nutritive sucking; and (3) heel lance treated with sucrose and non-nutritive sucking. Plasma markers of ATP degradation (hypoxanthine, xanthine, and uric acid) and oxidative stress (allantoin) were measured before and after the heel lance. Pain was measured with the Premature Infant Pain Profile. Data were analyzed by the use of repeated-measures ANOVA and Spearman rho.

RESULTS

We found significant increases in plasma hypoxanthine and uric acid over time in neonates who received sucrose. We also found a significant negative correlation between pain scores and plasma allantoin concentration in a subgroup of neonates who received sucrose.

CONCLUSION

A single dose of oral sucrose, given before heel lance, significantly increased ATP use and oxidative stress in premature neonates. Because neonates are given multiple doses of sucrose per day, randomized trials are needed to examine the effects of repeated sucrose administration on ATP degradation, oxidative stress, and cell injury.

Role of sucrose in reducing painful response to orogastric tube insertion in preterm neonates

OBJECTIVES

To study whether orogastric tube (OGT) insertion elicits a painful response in preterm neonates, and the role of oral sucrose in reducing this pain.

METHODS

This double blinded, randomized control trial was conducted in the neonatal intensive care units of Kalawati Saran Children's Hospital. Clinically stable preterms within the first 7 postnatal days, who had not received painful stimulus 30 min prior to intervention, and who required routine OGT insertion were included. Lingual 24 % sucrose or distilled water (1 ml) was administered 2 min before OGT insertion. The primary outcome was painful response assessed by Premature Infant Pain Profile scale (PIPP), while the secondary outcomes were heart rate and SpO2 changes. The trial is registered with ClinicalTrials.gov (

REGISTRATION NUMBER

NCT 00949104) RESULTS: Sixty preterms were randomized in each group. Final analysis was carried out on 52 subjects in the placebo group and 53 in the sucrose group. The mean intra-procedure PIPP scores were significantly higher than the mean pre-procedure PIPP scores, in the gestational age groups of more than 34 wk, and 32 wk to 33 wk, 6 d, in both the placebo (7.25 vs. 3, and 8.14 vs. 3.14, respectively) and sucrose arm (8.06 vs. 3.21, and 7.18 vs. 4.18, respectively). The mean PIPP scores assessed at 30 s post procedure in the sucrose group were significantly lower than the placebo group (4.32 vs. 5.6, p = 0.014). No significant adverse events were seen.

CONCLUSIONS

OGT insertion causes pain in preterms and single dose lingual 24 % sucrose may alleviate this pain.

Sucrose for analgesia in newborn infants undergoing painful procedures

BACKGROUND

Administration of oral sucrose with and without non-nutritive sucking is the most frequently studied non-pharmacological intervention for procedural pain relief in neonates.

OBJECTIVES

To determine the efficacy, effect of dose and safety of oral sucrose for relieving procedural pain in neonates.

SEARCH METHODS

We used the standard methods of the Cochrane Neonatal Review Group. Electronic and manual searches were performed in November 2011 for published randomised controlled trials (RCTs) in MEDLINE (1950 to November 2011), EMBASE (1980 to 2011), CINAHL (1982 to November 2011) and the Cochrane Central Register of Controlled Trials (The Cochrane Library). We did not impose language restrictions.

SELECTION CRITERIA

RCTs in which term, preterm, or both term and preterm neonates (postnatal age maximum of 28 days after reaching 40 weeks' postmenstrual age) received sucrose for procedural pain. Control conditions included no treatment, water, pacifier, positioning/containing or breastfeeding.

DATA COLLECTION AND ANALYSIS

Main outcome measures were physiological, behavioural, or both pain indicators with or without composite pain scores. A mean difference (MD) with 95% confidence intervals (CI) using the fixed-effect model was reported for continuous outcome measures. Trial quality was assessed as per The Cochrane Collaboration

MAIN RESULTS

Fifty-seven studies enrolling 4730 infants were included. Results from only a few studies could be combined in meta-analyses. When Premature Infant Pain Profile (PIPP) scores were pooled, sucrose groups had significantly lower scores at 30 seconds (weighted mean difference (WMD) -1.76; 95% CI -2.54 to - 0.97; 4 trials; 264 neonates] and 60 seconds (WMD -2.05; 95% CI -3.08 to -1.02; 3 trials' 195 neonates) post-heel lance. For retinopathy of prematurity (ROP) examinations, sucrose did not significantly reduce PIPP scores (WMD -0.65; 95% CI -1.88 to 0.59; 3 trials; 82 neonates). There were no differences in adverse effects between sucrose and control groups. Sucrose significantly reduced duration of total crying time (WMD -39 seconds; 95% CI -44 to -34; 2 trials; 88 neonates), but did not reduce duration of first cry during heel lance (WMD -9 seconds; 95% CI -20 to 2; 3 trials; 192 neonates). Oxygen saturation (%) was significantly lower in infants given sucrose during ROP examination compared to controls (WMD -2.6; 95% CI -4.9 to - 0.2; 2 trials; 62 neonates). Results of individual trials that could not be incorporated in meta-analyses supported these findings. The effects of sucrose on long-term neurodevelopmental outcomes are unknown.

AUTHORS' CONCLUSIONS

Sucrose is safe and effective for reducing procedural pain from single events. An optimal dose could not be identified due to inconsistency in effective sucrose dosage among studies. Further investigation on repeated administration of sucrose in neonates and the use of sucrose in combination with other non-pharmacological and pharmacological interventions is needed. Sucrose use in extremely preterm, unstable, ventilated (or a combination of these) neonates needs to be addressed. Additional research is needed to determine the minimally effective dose of sucrose during a single painful procedure and the effect of repeated sucrose administration on immediate (pain intensity) and long-term (neurodevelopmental) outcomes.

Sucrose for analgesia in newborn infants undergoing painful procedures

BACKGROUND

Administration of oral sucrose with and without non-nutritive sucking is frequently used as a non-pharmacological intervention for procedural pain relief in neonates.

OBJECTIVES

To determine the efficacy, effect of dose and safety of oral sucrose for relieving procedural pain in neonates.

SEARCH STRATEGY

The standard methods of the Cochrane Neonatal Collaborative Review Group were used.

SELECTION CRITERIA

Randomized controlled trials in which term and/or preterm neonates (postnatal age maximum of 28 days corrected for postmenstrual age) received sucrose for procedural pain. Control conditions included water, pacifier, positioning/containing or breastfeeding.

DATA COLLECTION AND ANALYSIS

The main outcome measures were physiological and/or behavioural pain indicators and/or composite pain scores. A weighted mean difference (WMD) with 95% confidence intervals (CI) using the fixed effects model was reported for continuous outcome measures.

MAIN RESULTS

Forty-four studies enrolling 3,496 infants were included. Results from only a few studies could be combined in meta-analyses. Sucrose significantly reduced duration of total crying time (seconds) [WMD -39.26 (95% CI -44.29, -34.24), 88 neonates], but did not reduce duration of first cry (seconds) during heel lance [WMD -8.99 (95% CI -20.07, 2.10), 192 neonates]. No significant differences were found for percent change in heart rate from baseline at one minute [WMD 0.90 (95% CI -5.81, 7.61), 86 neonates] and three minutes [WMD -6.20 (95% CI -15.27, 2.88), 86 neonates] post-heel lance, or for mean heart rate at three minutes post-heel lance [WMD -0.98 (95% CI -8.29, 6.32), 154 neonates]. Oxygen saturation (%) was significantly lower in infants given sucrose during ROP examination compared to controls [WMD -2.58 (95% CI -4.94, - 0.23), 62 neonates]. Infants given sucrose post-heel lance had significantly lower PIPP scores at 30 seconds [WMD -1.64 (95% CI -2.47, - 0.81), 220 neonates] and 60 seconds [WMD -2.05 (95% CI -3.08, -1.02), 195 neonates]. For ROP exams, sucrose did not significantly reduce PIPP scores [WMD -0.65 (95% CI -1.88, 0.59), 82 neonates]. There were no differences in adverse effects between sucrose and control groups.

AUTHORS' CONCLUSIONS

Sucrose is safe and effective for reducing procedural pain from single events. An optimal dose could not be identified due to inconsistency in effective sucrose dosage among studies.Further investigation on repeated administration of sucrose in neonates and the use of sucrose in combination with other non-pharmacological (e.g. behavioural, physical) and pharmacologic interventions is needed. Sucrose use in extremely low birth-weight and unstable and/or ventilated neonates needs to be addressed.

Analgesia in preterm newborns: the comparative effects of sucrose and glucose

The aim of this study was to evaluate the effectiveness of different oral carbohydrate solutions for alleviation of pain in healthy preterm babies. Thirty-one preterm infants who were having blood drawn by heel prick were given 2 ml of solution A (20% sucrose), solution B (20% glucose) or solution C (placebo, sterile water) into the mouth, 2 min before lancing. Behavioural responses to this painful stimulus were measured by duration of crying and facial expressions (Neonatal Facial Coding System, NFCS) and physiological responses were measured by heart rate (HR), respiratory rate (RR), and oxygen saturation changes (SaO(2)). Infants had a mean birth weight (+/-SD) of 1,401 g (406), gestational age of 30.5 weeks (2.7); at the time of the procedure the postmenstrual age was 32.3 weeks (1.5). There was no significant difference in the time spent squeezing the heel between the three groups (P = 0.669). After the heel prick of both the sucrose and glucose groups the duration of first cry and total crying time was significantly reduced (P = 0.005 and P = 0.007). When the babies received placebo they showed a significantly higher NFCS score at 4 and 5 min after the heel prick (P = 0.009 and 0.046 respectively). Following painful stimulus HR increased significantly in the first 3 min compared with baseline, and at the first minute the mean of the HR was found to be significantly higher in the placebo group than in the sucrose and glucose groups (P = 0.007). We concluded that both sucrose and glucose administered orally before a heel prick reduce the pain response in preterm infants.

[Systemic analgesia adapted to the children's condition]

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.

Effect of suckling on the peripheral sensitivity of full-term newborn infants

BACKGROUND

Sucking may reduce the manifestations of pain in newborn infants.

OBJECTIVE

To examine the effect of suckling on the threshold for peripheral somatosensory responses.

SUBJECTS AND METHODS

Graded Von Frey filaments were applied to the heel to initiate peripheral somatosensory responses (withdrawal reflex and gross body movements) in term infants.

RESULTS

Dummy sucking increases the somatosensory threshold, but breast feeding had a more marked effect, increasing the threshold of the flexion withdrawal reflex (p<or=0.002) and the threshold for gross body movements (p</=0.002).

CONCLUSION

Peripheral sensitivity of newborn infants is considerably reduced during sucking, particularly at the breast.

How effective is tetracaine 4% gel, before a venipuncture, in reducing procedural pain in infants: a randomized double-blind placebo controlled trial

BACKGROUND

Procedural pain relief is sub-optimal in neonates. Topical tetracaine provides pain relief in children. Evidence of its efficacy and safety in neonates is limited. The objective of this study was to assess the efficacy and safety of topical tetracaine on the pain response of neonates during a venipuncture.

METHODS

Medically stable infants greater than or equal to 24 weeks gestation, requiring a venipuncture, were included. Following randomization and double blinding, 1.1 g of tetracaine or placebo was applied to the skin for 30 minutes. Participants received oral sucrose if they met local eligibility criteria. The venipuncture was performed according to a standard protocol. A medium effect size in the pain score (corresponding to about 2 point difference in the PIPP score) was considered clinically significant, leading to a sample size of 142 infants, with 80% statistical power. Local skin reactions and immediate adverse cardiorespiratory events were noted. The primary outcome, PIPP score at 1 minute, was analysed using an independent Student's t-test.

RESULTS

One hundred and forty two infants were included, 33 +/- 4 weeks gestation, 2100 +/- 900 grams and 6 +/- 3 days of age. There was almost no difference in PIPP scores at 1 minute between groups (mean difference -0.09; 95% confidence interval [CI]: -1.68 to 1.50; P = . 91). Similarly, there were no differences in PIPP scores during the 2nd, 3rd and 4th minute. Duration of cry did not differ between the groups (median difference, 0; 95% CI, -3 to 0; P = . 84). The majority of infants in both groups received sucrose 24%. Sucrose had a significant effect on the PIPP score, as assessed by an ANOVA model (p = 0.0026). Local skin erythema was observed transiently in 11 infants (7 in the tetracaine and 4 in the placebo group). No serious side effect was observed.

CONCLUSION

Tetracaine did not significantly decrease procedural pain in infants undergoing a venipuncture, when used in combination with routine sucrose administration.

Common medical pains

Pain in infancy and childhood is extremely common. Sources of pain include illness, injury, and medical and dental procedures. Over the past two decades, tremendous progress has been made in the assessment, prevention and treatment of pain. It is important for the paediatric health care provider to be aware of the implications and consequences of pain in childhood. A multitude of interventions are available to reduce or alleviate pain in children of all ages, including neonates. These include behavioural and psychological methods, as well as a host of pharmacological preparations, which are safe and effective when used as indicated. Many complementary and alternative treatments appear to be promising in treating and relieving pain, although further research is required. The present article reviews the most common sources of pain in childhood and infancy, as well as current treatment strategies and options.

Prevention and management of pain in the neonate: an update

The prevention of pain in neonates should be the goal of all caregivers, because repeated painful exposures have the potential for deleterious consequences. Neonates at greatest risk of neurodevelopmental impairment as a result of preterm birth (ie, the smallest and sickest) are also those most likely to be exposed to the greatest number of painful stimuli in the NICU. Although there are major gaps in our knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underused for routine minor yet painful procedures. Every health care facility caring for neonates should implement an effective pain-prevention program, which includes strategies for routinely assessing pain, minimizing the number of painful procedures performed, effectively using pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and eliminating pain associated with surgery and other major procedures.

Sucrose and non-nutritive sucking for the relief of pain in screening for retinopathy of prematurity: a randomised controlled trial

BACKGROUND

Screening is necessary for infants at risk of retinopathy of prematurity. Despite local anaesthetic drops, infants find eye examinations distressing, displaying behavioural and physiological changes indicating acute pain. Oral sucrose and non-nutritive sucking reduce pain responses associated with invasive procedures.

OBJECTIVE

To evaluate the use of oral sucrose and/or pacifier for reducing pain responses during eye examinations.

METHODS

Forty infants <32 weeks gestation or <1500 g birth weight, in two neonatal units, were randomised to one of four interventions administered two minutes before their first screening examination: 1 ml sterile water as placebo (group 1, n = 10), 1 ml 33% sucrose solution (group 2, n = 10), 1 ml sterile water with pacifier (group 3, n = 9), or 1 ml 33% sucrose solution with pacifier (group 4, n = 11). Examinations were videotaped. Two observers, blind to the intervention, assessed recordings. Pain responses were scored using the premature infant pain profile (PIPP).

RESULTS

The groups were similar in gestation, birth weight, and age at examination. Mean PIPP scores were 15.3, 14.3, 12.3, and 12.1 for groups 1, 2, 3, and 4 respectively. Analysis of variance showed a significant difference in PIPP score between groups (p = 0.023). Infants randomised to pacifiers scored lower than those without pacifiers (p = 0.003). There was no difference between groups receiving sucrose and those receiving water (p = 0.321).

CONCLUSIONS

Non-nutritive sucking reduced distress responses in infants undergoing screening for retinopathy of prematurity. The difference in response was large enough to be detected by a validated assessment tool. No synergistic effect of sucrose and pacifier was apparent in this group.

Pediatric procedural pain

Pain is subjective. The pain response is individual and is learned through social learning and experience. Early pain experiences may play a particularly important role in shaping an individual's pain responses. Painful medical procedures such as immunizations, venipunctures and dental care, and minor emergency department procedures such as laceration repair, compose a significant portion of the average child's experience with painful events. Inadequate relief of pain and distress during childhood painful medical procedures may have long-term negative effects on future pain tolerance and pain responses. This article reviews the evidence for long-term negative effects of inadequately treated procedural pain, the determinants of an individual's pain response, tools to assess pain in children, and interventions to reduce procedural pain and distress. Future research directions and a model for conceptualizing and studying pediatric procedural pain are proposed.

Effet analgésique de la crème Emla®, du saccharose et de leur association pour les injections sous-cutanées chez le nouveau-né prématuré : étude prospective de 265 injections

OBJECTIVE

To compare the analgesic effects of non nutritive pacifier sucking, oral administration of a 30% saccharose solution, local application of Emla and their association for subcutaneous injection of erythropoietin (EPO) in preterm infants.

METHODS

Our study was a randomised, prospective study conducted over 5 months. Neonates with a gestational age below 33 weeks of gestation and older than 8 days of life were included if they were treated with EPO (three subcutaneous injections per week during 6 weeks). For each consecutive EPO injection, patients were randomised between four groups of intervention: non nutritive pacifier sucking (T), oral administration of 0.2-0.5 ml of a 30% saccharose solution with non nutritive pacifier sucking (S), local application of Emla with non nutritive pacifier sucking (E), and oral administration of 0.2-0.5 ml of a 30% saccharose solution with local application of Emla and with non nutritive pacifier sucking (S + E). Each child was its own control. Pain was assessed with the Newborn Acute Pain scale (DAN) and with the Neonatal Facial Coding System (NFCS).

RESULTS

Thirty-three neonates were included, representing 265 injections. Distribution was: 41 in group T, 71 in group E, 86 in group S and 67 in group E + S. Mean DAN and NFCS scores were statistically different between groups T, E and S. Analgesic effect of saccharose (-1.05) was greater than Emla (-0.56). Used together, effects were adding up without potentialisation.

CONCLUSION

This study shows that the association of non nutritive pacifier sucking with oral administration of saccharose and local application of Emla has a better analgesic effect than each of these three interventions alone for subcutaneous injection of EPO.

Érythropoïétine chez le nouveau-né : efficacité comparée des voies d’administration sous-cutanée et intraveineuse

OBJECTIVE

Our aim was to compare the effectiveness of a one-month treatment with recombinant human erythropoietine (rHuEpo) according to the administration route.

METHODS

Retrospective study based on the data collection from medical files of 64 preterm infant hospitalized in the "institut de puériculture et de périnatalogie" (Paris) between January 13th, 2002 and April 13th, 2002. The first group (N =33) was treated by subcutaneous rHuEpo 750 IU/kg per week, in three injections by week, for one month. The second group (N =15) was treated by continuous infusion of rHuEpo in total parenteral nutrition 1050 IU/kg per week (30% augmentation to compensate the amount absorbed by the filter). The third group (N =16) received 750 IU/kg per week of rHuEpo in three direct intravenous injections. The effectiveness of rHuEpo was evaluated by the absolute reticulocyte count, the level of hemoglobin and the incidence of blood transfusion (multiple logistic analysis of variant and regression).

RESULTS

The absolute reticulocyte count and hemoglobin level were significantly reduced after one month of treatment by continuous infusion of rHuEpo in total parenteral nutrition and direct intravenous injections compared with a one-month treatment by subcutaneous rHuEpo. Hemoglobine level were at 8.8 and 9.6 g/dl vs 10.3 g/dl (P =0.02) and absolute reticulocyte count at 123,000/mm3 and 190,000/mm3 vs 216,000/mm3 (p =0.001). The number of transfused infants was significantly increased with utilization of continuous (40%) and direct intravenous (75%) compared with those treated by subcutaneous route (21.2%) while the ferritin level and phlebotomy losses were not significantly different in the three groups. The number of blood transfusion was significantly linked to phlebotomy losses and administration route of rHuEpo.

CONCLUSION

Our study tends to demonstrate that rHuEpo administered subcutaneously reduces significantly the number of transfusion in contrary to intravenous routes. Waiting for pilot study and new molecules, we recommend subcutaneous administration of rHuEpo to preterm infants 250 IU/kg three times weekly in the treatment of anemia of prematurity.

Sucrose for analgesia in newborn infants undergoing painful procedures

BACKGROUND

Management of pain for neonates is less than optimal. The administration of sucrose with and without non-nutritive sucking (pacifiers) has been the most frequently studied non-pharmacological intervention for relief of procedural pain in neonates.

OBJECTIVES

To determine the efficacy, effect of dose, and safety of sucrose for relieving procedural pain as assessed by validated individual pain indicators and composite pain scores.

SEARCH STRATEGY

Standard methods as per the Neonatal Collaborative Review Group. A MEDLINE search was carried out for relevant randomized controlled trials (RCTs) published from January 1966 - March 2004, EMBASE from 1980-2004 and search of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2004). Key words and (MeSH) terms included infant/newborn, pain, analgesia and sucrose. Language restrictions were not imposed. Bibliographies, personal files, the most recent relevant neonatal and pain journals and recent major pediatric pain conference proceedings were searched manually. Unpublished studies, or studies reported only as abstracts, were not included. Additional information from published studies was obtained.

SELECTION CRITERIA

RCTs in which term and/or preterm neonates (postnatal age maximum of 28 days after reaching 40 weeks corrected gestational age) received sucrose via oral syringe, NG-tube, dropper or pacifier for procedural pain from heel lance or venepuncture. In the control group, water, pacifier or positioning/containing were used. Studies in which the painful stimulus was circumcision were excluded.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed according to the methods of the Neonatal Collaborative Review Group. Quality measures included blinding of randomization, blinding of intervention, completeness of follow up and blinding of outcome measurement. Data were abstracted and independently checked for accuracy by the three investigators.

STATISTICAL ANALYSIS

The statistical package (RevMan 4.2) of the Cochrane Collaboration was used. For meta-analysis, a weighted mean difference (WMD) with 95% confidence intervals (CI) using the fixed effects model was reported for continuous outcome measures.

MAIN RESULTS

Forty-four studies were identified for possible inclusion in this review. Seven studies reported only as abstracts, and sixteen additional studies were excluded, leaving 21 studies (1,616 infants) included in this review. Sucrose in a wide variety of dosages was generally found to decrease physiologic (heart rate) and behavioural (the mean percent time crying, total cry duration, duration of first cry, and facial action) pain indicators and composite pain scores in neonates undergoing heel stick or venepuncture. When pain scores (Premature Infant Pain Profiles) were pooled across 3 studies (Gibbins 2001; Johnston 1999a; Stevens 1999), they were significantly reduced in infants who were given sucrose (dose range 0.012 g to 0.12 g) compared to the control group, [WMD -1.64 (95% CI -2.47,- 0.81); p = 0.0001] at 30 seconds and [WMD -2.05, (95% CI -3.08, -1.02); p = 0.00010] at 60 seconds after heel lance. When results for change in heart rate were pooled for two studies (Haouari 1995, Isik 2000), there were no significant differences between changes in heart rate for infants given sucrose (dose range 0.5 g to 0.6 g) compared to the control group, [WMD 0.90 (95% CI -5.81, 7.61); p = 0.8] at one minute and [WMD -6.20 (95% CI -15.27, 2.88); p = 0.18] at three minutes after heel lance.

REVIEWERS' CONCLUSIONS

Sucrose is safe and effective for reducing procedural pain from single painful events (heel lance, venepuncture). There was inconsistency in the dose of sucrose that was effective (dose range of 0.012 g to 0.12 g), and therefore an optimal dose to be used in preterm and/or term infants could not be identified. The use of repeated administrations of sucrose in neonates needs to be investigated as does the use of sucrose in combination with other behavioural (e.g., facilitated tucking, kangaroo care) and pharmacologic (e.g., morphine, fentanyl) interventions. Use of sucrose in neonates who are of very low birth weight, unstable and/or ventilated also needs to be addressed.

Analgesic effect of breast feeding in term neonates: randomised controlled trial

OBJECTIVES

To investigate whether breast feeding is effective for pain relief during venepuncture in term neonates and compare any effect with that of oral glucose combined with a pacifier.

DESIGN

Randomised controlled trial.

PARTICIPANTS

180 term newborn infants undergoing venepuncture; 45 in each group.

INTERVENTIONS

During venepuncture infants were either breast fed (group 1), held in their mother's arms without breast feeding (group 2), given 1 ml of sterile water as placebo (group 3), or given 1 ml of 30% glucose followed by pacifier (group 4). Video recordings of the procedure were assessed by two observers blinded to the purpose of the study.

MAIN OUTCOME MEASURES

Pain related behaviours evaluated with two acute pain rating scales: the Douleur Aiguë Nouveau-né scale (range 0 to 10) and the premature infant pain profile scale (range 0 to 18).

RESULTS

Median pain scores (interquartile range) for breast feeding, held in mother's arms, placebo, and 30% glucose plus pacifier groups were 1 (0-3), 10 (8.5-10), 10 (7.5-10), and 3 (0-5) with the Douleur Aiguë Nouveau-né scale and 4.5 (2.25-8), 13 (10.5-15), 12 (9-13), and 4 (1-6) with the premature infant pain profile scale. Analysis of variance showed significantly different median pain scores (P<0.0001) among the groups. There were significant reductions in both scores for the breast feeding and glucose plus pacifier groups compared with the other two groups (P<0.0001, two tailed Mann-Whitney U tests between groups). The difference in Douleur Aiguë Nouveau-né scores between breast feeding and glucose plus pacifier groups was not significant (P=0.16).

CONCLUSIONS

Breast feeding effectively reduces response to pain during minor invasive procedure in term neonates.

Crossover trial of analgesic efficacy of glucose and pacifier in very preterm neonates during subcutaneous injections

OBJECTIVE

Very preterm newborns undergo multiple invasive procedures. Nonpharmacological interventions are valuable alternatives for pain relief during minor procedures in neonates. Oral sucrose analgesia has been widely studied in term and preterm neonates during painful procedures. The analgesic effect of oral glucose in very preterm infants has not yet been reported. The objectives of this study were to assess the analgesic effect of orally administered glucose and to determine the synergetic analgesic effect of glucose and pacifiers during subcutaneous injections in very preterm neonates using a validated behavioral acute pain rating scale.

DESIGN

Two crossover trials.

SETTING

One neonatal intensive care unit in a community-based general hospital.

METHODS

A prospective study was conducted in 40 very preterm neonates. Each infant received 2 treatments in a crossover manner during 2 consecutive subcutaneous injections of erythropoietin. The first trial (25 infants) was intended to compare oral 30% glucose (0.3 mL) versus placebo (0.3 mL of sterile water); the second trial (15 infants) compared oral 30% glucose (0.3 mL) versus oral 30% glucose (0.3 mL) followed by sucking a pacifier. The primary outcome measure was the evaluation of pain induced by a subcutaneous injection of erythropoietin, using Douleur Aiguë Nouveau-né scale (0 no pain, 10 maximum pain).

RESULTS

Twenty-four infants completed the study in the first trial and 15 in the second one. Mean (95% confidence interval [CI]) gestational age, birth weight, postnatal age, and weight at inclusion for neonates in the first and second trial were, respectively, 28.1 (95% CI: 27.3-29.0) and 29.1 (95% CI: 27.8-30.4) weeks, 1036 (95% CI: 944-1128) and 995 (95% CI: 848-1141) g, 26.4 (95% CI: 22.4-30.3) and 26 (95% CI: 22.0-29.9) days, and 1234 (95% CI: 1120-1348) and 1209 (95% CI: 1059-1359) g. In the first trial, median (interquartile) pain scores for placebo and 30% glucose, respectively, were 7 (2.5-9.75) and 4.5 (1-6). In the second trial, median (interquartile) pain scores for 30% glucose and for 30% glucose plus pacifier, respectively, were 4 (2-7) and 4 (1-6).

CONCLUSIONS

A small dose of 0.3 mL of 30% oral glucose has an analgesic effect in very preterm neonates during subcutaneous injections. This effect is clinically evident because it can be detected by a behavioral pain rating scale. The synergetic analgesic effect of glucose plus sucking a pacifier is less obvious in very preterm neonates as opposed to what other studies have showed in full-term infants.

Breastfeeding is analgesic in healthy newborns

CONTEXT

This study identifies a behavioral and nonpharmacologic means of preventing newborn pain.

OBJECTIVE

To determine whether breastfeeding is analgesic in newborn infants undergoing heel lance-a routine, painful, hospital procedure.

DESIGN

A prospective, randomized, controlled trial.

SETTING

Hospital maternity services at Boston Medical Center, Boston, Massachusetts, and Beverly Hospital, Beverly, Massachusetts.

PARTICIPANTS

A random sample of 30 full-term, breastfed infants.

INTERVENTIONS

Infants in the intervention group were held and breastfed by their mothers during heel lance and blood collection procedures for the Newborn Screening Program Blood Test. Infants in the control group experienced the same blood test while receiving the standard hospital care of being swaddled in their bassinets.

OUTCOMES MEASURES

Crying, grimacing, and heart rate differences were analyzed between the breastfeeding and the control infants before, during, and after blood collection.

RESULTS

Crying and grimacing were reduced by 91% and 84%, respectively, from control infant levels during the blood collection. Heart rate was also substantially reduced by breastfeeding.

CONCLUSIONS

Breastfeeding is a potent analgesic intervention in newborns during a standard blood collection.

Infant crying: nature, physiologic consequences, and select interventions

This article describes the nature of infant crying, the physiologic events and changes associated with it, and appropriate nursing interventions for infant crying. A cry is a series of four movements that basically resembles a Valsalva maneuver. Documented immediate and long-term sequelae of crying include increased heart rate and blood pressure, reduced oxygen level, elevated cerebral blood pressure, initiation of the stress response, depleted energy reserves and oxygen, interrupted mother-infant interaction, brain injury, and cardiac dysfunction. Caregivers are encouraged to answer infant cries swiftly, consistently, and comprehensively. Kangaroo care is an efficient method for preventing, minimizing, and halting crying. Other interventions for crying include swaddled holding, a pacifier, sugar water, a sweet-tasting nonsucrose solution, heartbeat sounds, distraction by lullabies or mother's voice, rhythmic movement, and reduction of external stimuli.