Suckling- and sucrose-induced analgesia in human newborns

An Analgesic Technique for Orogastric Tube Insertion in Newborns: DOLATSONG, a Randomized Multicentric Controlled Trial

BACKGROUND

Gastric tube insertion is necessary to support early enteral feeding of newborns during their neonatal intensive care stay. This frequent and invasive procedure is known to be painful. Very few analgesic techniques (sweet solutions, sucking, swaddling, and skin-to-skin contact) are available to reduce the pain caused by orogastric tube insertion procedure.

OBJECTIVE

To determine whether a new orogastric tube insertion technique modifies the pain response in newborns, we hypothesize that inserting an orogastric tube through the nipple of a bottle reduces pain caused by this procedure.

DESIGN

Prospective, controlled, randomized, multicentered and open label study.

SETTINGS

Three neonatal intensive care units in France (2 level 3 units and 1 level 2B).

PARTICIPANTS

Full-term or premature newborns at 32 weeks of gestation or more, postnatal age between 48 hours and 21 days, not ventilated and requiring enteral feeding, were randomized into 2 groups: usual technique (n = 36) and experimental technique (n = 35).

METHODS

Our experimental technique was to insert the orogastric tube through a modified nipple of a bottle. This method was compared with the usual technique of inserting the tube directly into the newborn's mouth without a support to guide it accompanied by a nipple encouraging sucking with a nonnutritive solution. An association of nonnutritive sucking and orally administered 30% glucose was given to all children for analgesic purposes. Pain during the orogastric tube insertion was assessed on video recordings by 2 independent experts, using a heteroassessment behavioral scale for pain (DAN-Douleur Aiguë du Nouveau-né; APN-Acute Pain in Newborns). The primary outcome was an Acute Pain in Newborns score of less than 3 at the time of the procedure. Comparisons were made using Fisher exact test or Mann-Whitney U test. Factors associated with an Acute Pain in Newborns score of 3 and greater were explored using univariable and multivariable regression models.

RESULTS

All but 1 video recording in each group were analyzed. Among the 34 neonates in the experimental group, 71.4% (95% CI: [53.7-85.4]) had an Acute Pain in Newborns score of less than 3 during orogastric tube insertion versus 41% (95% CI: [27.9-61.9]) in the control group (P = .031). Gagging was frequent and nonsignificantly different between the 2 groups (69% in the control group, 51% in the experimental group, P = .13). In multivariable analysis, the experimental technique was an independent factor of pain prevention compared with the usual technique (odds ratio = 0.21 [0.06-0.71], P = .015).

CONCLUSIONS

This study suggests that a simple, inexpensive, and feasible technique of orogastric tube insertion through the nipple of a bottle limits pain associated with this procedure in newborns.

Sucrose analgesia for heel-lance procedures in neonates

BACKGROUND

Sucrose has been examined for calming and pain-relieving effects in neonates for invasive procedures such as heel lance.

OBJECTIVES

To assess the effectiveness of sucrose for relieving pain from heel lance in neonates in terms of immediate and long-term outcomes SEARCH METHODS: We searched (February 2022): CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and three trial registries.

SELECTION CRITERIA

We included randomised controlled trials where term and/or preterm neonates received sucrose for heel lances. Comparison treatments included water/placebo/no intervention, non-nutritive sucking (NNS), glucose, breastfeeding, breast milk, music, acupuncture, facilitated tucking, and skin-to-skin care.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We reported mean differences (MD) with 95% confidence intervals (CI) using the fixed-effect model for continuous outcome measures. We assessed heterogeneity by the I2 test. We used GRADE to assess certainty of evidence.

MAIN RESULTS

We included 55 trials (6273 infants): 29 included term neonates, 22 included preterm neonates, and four included both. Heel lance was investigated in 50 trials; 15 investigated other minor painful procedures in addition to lancing. Sucrose vs control The evidence suggests that sucrose probably results in a reduction in PIPP scores compared to the control group at 30 seconds (MD -1.74 (95% CI -2.11 to -1.37); I2 = 62%; moderate-certainty evidence) and 60 seconds after lancing (MD -2.14, 95% CI -3.34 to -0.94; I2 = 0%; moderate-certainty evidence). The evidence is very uncertain about the effects of sucrose on DAN scores compared to water at 30 seconds after lancing (MD -1.90, 95% CI -8.58 to 4.78; heterogeneity not applicable (N/A); very low-certainty evidence). The evidence suggests that sucrose probably results in a reduction in NIPS scores compared to water immediately after lancing (MD -2.00, 95% CI -2.42 to -1.58; heterogeneity N/A; moderate-certainty evidence). Sucrose vs NNS The evidence is very uncertain about the effect of sucrose on PIPP scores compared to NNS during the recovery period after lancing (MD 0.60, 95% CI -0.30 to 1.50; heterogeneity not applicable; very low-certainty evidence) and on DAN scores at 30 seconds after lancing (MD -1.20, 95% CI -7.87 to 5.47; heterogeneity N/A; very low-certainty evidence). Sucrose + NNS vs NNS The evidence is very uncertain about the effect of sucrose + NNS on PIPP scores compared to NNS during lancing (MD -4.90, 95% CI -5.73 to -4.07; heterogeneity not applicable; very low-certainty evidence) and during recovery after lancing (MD -3.80, 95% CI -4.47 to -3.13; heterogeneity N/A; very low-certainty evidence). The evidence is very uncertain about the effects of sucrose + NNS on NFCS scores compared to water + NNS during lancing (MD -0.60, 95% CI -1.47 to 0.27; heterogeneity N/A; very low-certainty evidence). Sucrose vs glucose The evidence suggests that sucrose results in little to no difference in PIPP scores compared to glucose at 30 seconds (MD 0.26, 95% CI -0.70 to 1.22; heterogeneity not applicable; low-certainty evidence) and 60 seconds after lancing (MD -0.02, 95% CI -0.79 to 0.75; heterogeneity N/A; low-certainty evidence). Sucrose vs breastfeeding The evidence is very uncertain about the effect of sucrose on PIPP scores compared to breastfeeding at 30 seconds after lancing (MD -0.70, 95% CI -0.49 to 1.88; I2 = 94%; very low-certainty evidence). The evidence is very uncertain about the effect of sucrose on COMFORTneo scores compared to breastfeeding after lancing (MD -2.60, 95% CI -3.06 to -2.14; heterogeneity N/A; very low-certainty evidence). Sucrose vs expressed breast milk The evidence suggests that sucrose may result in little to no difference in PIPP-R scores compared to expressed breast milk during (MD 0.3, 95% CI -0.24 to 0.84; heterogeneity not applicable; low-certainty evidence) and at 30 seconds after lancing (MD 0.3, 95% CI -0.11 to 0.71; heterogeneity N/A; low-certainty evidence). The evidence suggests that sucrose probably may result in slightly increased PIPP-R scores compared to expressed breast milk 60 seconds after lancing (MD 1.10, 95% CI 0.34 to 1.86; heterogeneity N/A; low-certainty evidence). The evidence is very uncertain about the effect of sucrose on DAN scores compared to expressed breast milk 30 seconds after lancing (MD -1.80, 95% CI -8.47 to 4.87; heterogeneity N/A; very low-certainty evidence). Sucrose vs laser acupuncture There was no difference in PIPP-R scores between sucrose and music groups; however, data were reported as medians and IQRs. The evidence is very uncertain about the effect of sucrose on NIPS scores compared to laser acupuncture during lancing (MD -0.86, 95% CI -1.43 to -0.29; heterogeneity N/A; very low-certainty evidence). Sucrose vs facilitated tucking The evidence is very uncertain about the effect of sucrose on total BPSN scores compared to facilitated tucking during lancing (MD -2.27, 95% CI -4.66 to 0.12; heterogeneity N/A; very low-certainty evidence) and during recovery after lancing (MD -0.31, 95% CI -1.72 to 1.10; heterogeneity N/A; very low-certainty evidence). Sucrose vs skin-to-skin + water (repeated lancing) The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin-to-skin + water at 30 seconds after 1st (MD 0.13, 95% CI -0.70 to 0.96); 2nd (MD -0.56, 95% CI -1.57 to 0.45); or 3rd lancing (MD-0.15, 95% CI -1.26 to 0.96); heterogeneity N/A, low-certainty evidence for all comparisons. The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin-to-skin + water at 60 seconds after 1st (MD -0.61, 95% CI -1.55 to 0.33); 2nd (MD -0.12, 95% CI -0.99 to 0.75); or 3rd lancing (MD-0.40, 95% CI -1.48 to 0.68); heterogeneity N/A, low-certainty evidence for all comparisons. Minor adverse events required no intervention.

AUTHORS' CONCLUSIONS

Sucrose compared to control probably results in a reduction of PIPP scores 30 and 60 seconds after single heel lances (moderate-certainty evidence). Evidence is very uncertain about the effect of sucrose compared to NNS, breastfeeding, laser acupuncture, facilitated tucking, and the effect of sucrose + NNS compared to NNS in reducing pain. Sucrose compared to glucose, expressed breast milk, and skin-to-skin care shows little to no difference in pain scores. Sucrose combined with other nonpharmacologic interventions should be used with caution, given the uncertainty of evidence.

The physiology, assessment, and treatment of neonatal pain

Studies have clearly shown that development of pain receptors starts as early as 20-weeks' gestation. Despite contrary belief, the human fetus develops a similar number of receptive pain fibers as seen in adults. These receptors' maturation is based on response to sensory stimuli received after birth which makes the NICU a critical place for developing central nervous system's pain perception. In practice, the assessment of pain relies mostly on bedside staff. In this review we will discuss the various developing features of pain pathways in the neonatal brain and the modification of pain perception secondary to various interactions immediately after birth. We also discuss the various tools utilized in the NICU for pain assessment that rely on physiological and behavioral patterns. Finally, we address the management of pain in the NICU by either pharmacological or non-pharmacological intervention while highlighting potential benefits, disadvantages, and situations where one may be preferred over another.

Non-pharmacological management of infant and young child procedural pain

BACKGROUND

Despite evidence of the long-term implications of unrelieved pain during infancy, it is evident that infant pain is still under-managed and unmanaged. Inadequately managed pain in infancy, a period of exponential development, can have implications across the lifespan. Therefore, a comprehensive and systematic review of pain management strategies is integral to appropriate infant pain management. This is an update of a previously published review update in the Cochrane Database of Systematic Reviews (2015, Issue 12) of the same title.

OBJECTIVES

To assess the efficacy and adverse events of non-pharmacological interventions for infant and child (aged up to three years) acute pain, excluding kangaroo care, sucrose, breastfeeding/breast milk, and music.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE-Ovid platform, EMBASE-OVID platform, PsycINFO-OVID platform, CINAHL-EBSCO platform and trial registration websites (ClinicalTrials.gov; International Clinical Trials Registry Platform) (March 2015 to October 2020). An update search was completed in July 2022, but studies identified at this point were added to 'Awaiting classification' for a future update.  We also searched reference lists and contacted researchers via electronic list-serves.  We incorporated 76 new studies into the review.  SELECTION CRITERIA: Participants included infants from birth to three years in randomised controlled trials (RCTs) or cross-over RCTs that had a no-treatment control comparison. Studies were eligible for inclusion in the analysis if they compared a non-pharmacological pain management strategy to a no-treatment control group (15 different strategies). In addition, we also analysed studies when the unique effect of adding a non-pharmacological pain management strategy onto another pain management strategy could be assessed (i.e. additive effects on a sweet solution, non-nutritive sucking, or swaddling) (three strategies). The eligible control groups for these additive studies were sweet solution only, non-nutritive sucking only, or swaddling only, respectively. Finally, we qualitatively described six interventions that met the eligibility criteria for inclusion in the review, but not in the analysis.  DATA COLLECTION AND ANALYSIS: The outcomes assessed in the review were pain response (reactivity and regulation) and adverse events. The level of certainty in the evidence and risk of bias were based on the Cochrane risk of bias tool and the GRADE approach. We analysed the standardised mean difference (SMD) using the generic inverse variance method to determine effect sizes.  MAIN RESULTS: We included total of 138 studies (11,058 participants), which includes an additional 76 new studies for this update. Of these 138 studies, we analysed 115 (9048 participants) and described 23 (2010 participants) qualitatively. We described qualitatively studies that could not be meta-analysed due to being the only studies in their category or statistical reporting issues. We report the results of the 138 included studies here. An SMD effect size of 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect. The thresholds for the I2 interpretation were established as follows: not important (0% to 40%); moderate heterogeneity (30% to 60%); substantial heterogeneity (50% to 90%); considerable heterogeneity (75% to 100%). The most commonly studied acute procedures were heel sticks (63 studies) and needlestick procedures for the purposes of vaccines/vitamins (35 studies). We judged most studies to have high risk of bias (103 out of 138), with the most common methodological concerns relating to blinding of personnel and outcome assessors. Pain responses were examined during two separate pain phases: pain reactivity (within the first 30 seconds after the acutely painful stimulus) and immediate pain regulation (after the first 30 seconds following the acutely painful stimulus). We report below the strategies with the strongest evidence base for each age group. In preterm born neonates, non-nutritive sucking may reduce pain reactivity (SMD -0.57, 95% confidence interval (CI) -1.03 to -0.11, moderate effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.61, 95% CI -0.95 to -0.27, moderate effect; I2 = 81%, considerable heterogeneity), based on very low-certainty evidence. Facilitated tucking may also reduce pain reactivity (SMD -1.01, 95% CI -1.44 to -0.58, large effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.59, 95% CI -0.92 to -0.26, moderate effect; I2 = 87%, considerable heterogeneity); however, this is also based on very low-certainty evidence. While swaddling likely does not reduce pain reactivity in preterm neonates (SMD -0.60, 95% CI -1.23 to 0.04, no effect; I2 = 91%, considerable heterogeneity), it has been shown to possibly improve immediate pain regulation (SMD -1.21, 95% CI -2.05 to -0.38, large effect; I2 = 89%, considerable heterogeneity), based on very low-certainty evidence. In full-term born neonates, non-nutritive sucking may reduce pain reactivity (SMD -1.13, 95% CI -1.57 to -0.68, large effect; I2 = 82%, considerable heterogeneity) and improve immediate pain regulation (SMD -1.49, 95% CI -2.20 to -0.78, large effect; I2 = 92%, considerable heterogeneity), based on very low-certainty evidence.  In full-term born older infants, structured parent involvement was the intervention most studied. Results showed that this intervention has little to no effect in reducing pain reactivity (SMD -0.18, 95% CI -0.40 to 0.03, no effect; I2 = 46%, moderate heterogeneity) or improving immediate pain regulation (SMD -0.09, 95% CI -0.40 to 0.21, no effect; I2 = 74%, substantial heterogeneity), based on low- to moderate-certainty evidence. Of these five interventions most studied, only two studies observed adverse events, specifically vomiting (one preterm neonate) and desaturation (one full-term neonate hospitalised in the NICU) following the non-nutritive sucking intervention. The presence of considerable heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of evidence of very low to low certainty based on GRADE judgements.

AUTHORS' CONCLUSIONS

Overall, non-nutritive sucking, facilitated tucking, and swaddling may reduce pain behaviours in preterm born neonates. Non-nutritive sucking may also reduce pain behaviours in full-term neonates. No interventions based on a substantial body of evidence showed promise in reducing pain behaviours in older infants. Most analyses were based on very low- or low-certainty grades of evidence and none were based on high-certainty evidence. Therefore, the lack of confidence in the evidence would require further research before we could draw a definitive conclusion.

Nutritional geometry framework of sucrose taste in Drosophila

Dietary protein (P) and carbohydrate (C) have a major impact on sweet taste sensation. However, it remains unclear whether the balance of P and C influences sweet taste sensitivity. Here, we use the nutritional geometry framework (NGF) to address the interaction of protein and carbohydrates and on sweet taste using Drosophila as a model. Our results reveal that high-protein, low-carbohydrate (HPLC) diets sensitize to sweet taste and low-protein, high-carbohydrate (LPHC) diets desensitize sweet taste in both male and female flies. We further investigate the underlying mechanisms of these two diets' effect on sweet taste using RNA sequencing. When compared to the LPHC diet, the mRNA expression of genes involved in the metabolism of glycine, serine, and threonine is significantly upregulated in the HPLC diet, suggesting these amino acids may mediate sweet taste perception. We further find that sweet sensitization occurs in flies fed with the LPHC diet supplemented with serine and threonine. Our study demonstrates that sucrose taste sensitivity is affected by the balance of dietary protein and carbohydrates possibly through changes in serine and threonine.

Development of locally relevant clinical guidelines for procedure-related neonatal analgesic practice in Kenya: a systematic review and meta-analysis

Background Increasing numbers of neonates are undergoing painful procedures in low-income and middle-income countries, with adequate analgesia seldom used. In collaboration with a multi-disciplinary team in Kenya, we aimed to establish the first evidence-based guidelines for the management of routine procedure-related neonatal pain that consider low-resource hospital settings.

METHODS

We did a systematic review by searching MEDLINE, Embase, CINAHL, and CENTRAL databases for studies published from Jan 1, 1953, to March 31, 2019. We included data from randomised controlled trials using heart rate, oxygen saturation (SpO2), premature infant pain profile (PIPP) score, neonatal infant pain scale (NIPS) score, neonatal facial coding system score, and douleur aiguë du nouveau-né scale score as pain outcome measures. We excluded studies in which neonates were undergoing circumcision or were intubated, studies from which data were unextractable, or when pain was scored by non-trained individuals. We did a narrative synthesis of all studies, and meta-analysis when data were available from multiple studies comparing the same analgesics and controls and using the same outcome measures. 17 Kenyan health-care professionals formed our clinical guideline development panel, and we used the Grading of Recommendations, Assessment, Development and Evaluation framework and the panel's knowledge of the local health-care context to guide the guideline development process. This study is registered with PROSPERO, CRD42019126620.

FINDINGS

Of 2782 studies assessed for eligibility, data from 149 (5%) were analysed, with 80 (3%) of these further contributing to our meta-analysis. We found a high level of certainty for the superiority of breastfeeding over placebo or no intervention (standardised mean differences [SMDs] were -1·40 [95% CI -1·96 to -0·84] in PIPP score and -2·20 [-2·91 to -1·48] in NIPS score), and the superiority of oral sugar solutions over placebo or no intervention (SMDs were -0·38 [-0·61 to -0·16] in heart rate and 0·23 [0·04 to 0·42] in SpO2). We found a moderate level of certainty for the superiority for expressed breastmilk over placebo or no intervention (SMDs were -0·46 [95% CI -0·87 to -0·05] in heart rate and 0·48 [0·20 to 0·75] in SpO2). Therefore, the panel recommended that breastfeeding should be given as first-line analgesic treatment, initiated at least 2 min pre-procedure. Given contextual factors, for neonates who are unable to breastfeed, 1-2 mL of expressed breastmilk should be given as first-line analgesic, or 1-2 mL of oral sugar (≥10% concentration) as second-line analgesic. The panel also recommended parental presence during procedures with adjunctive provision of skin-to-skin care, or non-nutritive sucking when possible.

INTERPRETATION

We have generated Kenya's first neonatal analgesic guidelines for routine procedures, which have been adopted by the Kenyan Ministry of Health, and have shown a framework for clinical guideline development that is applicable to other low-income and middle-income health-care settings.

FUNDING

Wellcome Trust Research Programme, and the Africa-Oxford Initiative.

Effect of nutritive and non-nutritive sweeteners on hemodynamic responses to acute stress: a randomized crossover trial in healthy women

Background

The mechanisms by which chronic stress increases the risk of non-communicable diseases remain poorly understood. On one hand, chronic stress may increase systemic vascular resistance (SVR) and blood pressure, which may lead to blood vessels injury and altered myocardial perfusion. On the other hand, chronic stress may promote the overconsumption of sugar-containing foods and favor obesity. There is indeed evidence that sweet foods are preferentially consumed to alleviate stress responses. The effects of nutritive and non-nutritive sweeteners (NNS) on hemodynamic stress responses remain however largely unknown.

Objective/design

This study aimed at comparing the effects of sucrose-containing and NNS-containing drinks, as compared to unsweetened water, on hemodynamic responses to acute stress in twelve healthy female subjects. Acute stress responses were elicited by a 30-min mental stress (5-min Stroop’s test alternated with 5-min mental arithmetic) and a 3-min cold pressure test (CPT), each preceded by a resting baseline period. Hemodynamic stress responses were investigated by the repeated measurement of mean arterial pressure and the continuous monitoring of cardiac output by thoracic electrical bioimpedance measurement. SVR was selected as a primary outcome because it is a sensitive measure of hemodynamic responses to acute stress procedures.

Results

With all three drinks, SVR were not changed with mental stress (P = 0.437), but were increased with CPT (P = 0.045). Both mental stress and CPT increased mean arterial pressure and heart rate (all P < 0.001). Cardiac output increased with mental stress (P < 0.001) and remained unchanged with CPT (P = 0.252). No significant differences in hemodynamic responses were observed between water, sucrose and NNS (stress × condition, all P > 0.05).

Conclusions

These results demonstrate that sucrose and NNS do not alter hemodynamic responses to two different standardized acute stress protocols.

Nonpharmacologic Management of Pain During Common Needle Puncture Procedures in Infants: Current Research Evidence and Practical Considerations: An Update

Infants undergo painful procedures involving skin puncture as part of routine medical care. Pain from needle puncture procedures is suboptimally managed. Numerous nonpharmacologic interventions are available that may be used for these painful procedures, including swaddling/containment, pacifier/non-nutritive sucking, rocking/holding, breastfeeding and breastmilk, skin-to-skin care, sweet tasting solutions, music therapy, sensorial saturation, and parental presence. Adoption these interventions into routine clinical practice is feasible and should be a standard of care in quality health care for infants. This review summarizes the epidemiology of pain from common needle puncture procedures in infants, the effectiveness of nonpharmacologic interventions, implementation considerations, and unanswered questions.

Clinical characteristics of premature infants who orally feed on continuous positive airway pressure

BACKGROUND

Between 32 and 34 weeks postconceptional age (PCA), premature infants typically achieve neuromuscular maturation to initiate the coordination of a nutritive suck triad. Many premature infants also require intubation, which has been associated with dysphagia in adults and infants. At our institution, despite these factors, some infants have been noted to tolerate oral feeds while on continuous positive airway pressure (CPAP).

AIMS

Compare the clinical characteristics and duration of intubation in infants that initiate oral feedings on CPAP to infants that did not begin oral feeding on CPAP.

STUDY DESIGN

Retrospective case control study.

SUBJECTS

Infants with gestational age < 32 weeks who required CPAP at 32 weeks PCA.

OUTCOME MEASURES

Oral feeding was defined as any oral feed ≥5 ml. Duration of intubation was defined as the number of intubated days prior to 32 weeks PCA.

RESULTS

Of the 243 infants on CPAP at 32 weeks PCA, 31% (n = 76) began oral feeding on CPAP. Infants who initiated oral feeding on CPAP were of younger gestational age at birth (median 26 versus 27 weeks, p < 0.001) and remained intubated for longer (median 10.5 versus 2 days, p < 0.001).

CONCLUSIONS

Infants who began oral feeding on CPAP had lower gestational age and longer duration of intubation than infants who started oral feeding off CPAP.

Feeding-Induced Cortisol Response in Newborn Infants

CONTEXT

Understanding the biological rhythms and stress response in sick newborns is important to minimize the negative effects of intensive care. Salivary cortisol has been used as a noninvasive surrogate marker of adrenal function; however, understanding of its control variables is insufficient.

OBJECTIVE

To investigate the presence of feeding-induced cortisol response and its control variables in newborns.

DESIGN, SETTING, AND PATIENTS

Fifty-three newborn infants, who were between 30 and 40 weeks' corrected age and were on 3-hourly regular oral/enteral feeding, were recruited between January 2013 and June 2014.

MAIN OUTCOME MEASURE

Saliva samples were collected before and 1 hour after regular feeding. Dependence of cortisol levels (adjusted for postnatal age) and their feeding-related elevation on clinical variables was assessed by using generalized estimating equations.

RESULTS

Higher cortisol levels were associated with corrected age ≥37 weeks and saliva samples collected after feeding (both P < 0.001). Oral feeding was associated with a greater feeding-induced cortisol response compared with exclusive enteral feeding (P = 0.034), whereas a prolonged feeding duration (≥30 minutes) was associated with a reduced cortisol response compared with brief feeding (<30 minutes) (P < 0.001). Gestational age, corrected age, antenatal/postnatal glucocorticoids, type of milk, and daily feeding volume had no effect on cortisol response.

CONCLUSIONS

Feeding-induced cortisol response was observed in newborns. The cortisol response was more prominent following oral feeding and was reduced with prolonged feeding. Future studies may investigate whether feeding-induced cortisol response plays a role in the acquisition of adrenal ultradian and diurnal rhythms.

Infant Analgesia With a Combination of Breast Milk, Glucose, or Maternal Holding

OBJECTIVES

We studied neonatal cortical brain response to 4 types of nonpharmacological analgesia (oral glucose, expressed breast milk, maternal holding plus oral glucose, breastfeeding). We aimed to assess the differential effect of oral solutions (glucose, breast milk) given alone or combined with the maternal-infant relationship (holding, breastfeeding).

METHODS

Eighty healthy term newborns undergoing a heel stick were randomly assigned to 4 parallel groups of 20 infants each: group 1, infants received a glucose solution on a changing table; group 2, infants received expressed breast milk on a changing table; group 3, infants received a glucose solution in their mothers' arms; and group 4, infants were breastfed by their mothers. Cortical activation in parietal, temporal, and frontal cortices was assessed by multichannel near-infrared spectroscopy. Pain expression was also evaluated.

RESULTS

Oral glucose alone or combined with maternal holding was associated with no cortical activation during heel stick. Expressed breast milk was associated with localized bilateral activation of somatosensory and motor cortices (P < .01). Breastfeeding was associated with extensive bilateral activation of somatomotor, somatosensory, and right parietal cortices (P < .01). Pain expression was lower with the maternal-infant relationship (P = .007).

CONCLUSIONS

Oral glucose, either alone or combined with maternal holding, appears to block or weaken cortical pain processing. Breast milk alone is associated with localized cortical activation. Breastfeeding is associated with extensive activation and may act by extending cortical processing. Maternal relationship, both combined with oral glucose and in breastfeeding, shows the greatest analgesic effect, although the neural patterns involved are distributed differently.

Nascent body ego: Metapsychological and neurophysiological aspects

For Freud, body ego was the organizing basis of the structural theory. He defined it as a psychic projection of the body surface. Isakower's and Lewin's classical findings suggest that the body surface experiences of nursing provide the infant with sensory-affective stimulation that initiates a projection of sensory processes towards the psychic realm. During nursing, somato-sensory, gustatory and olfactory modalities merge with a primitive somatic affect of satiation, whereas auditory modality is involved more indirectly and visual contact more gradually. Repeated regularly, such nascent experiences are likely to play a part in the organization of the primitive protosymbolic mental experience. In support of this hypothesis, the authors review findings from a neurophysiological study of infants before, during and after nursing. Nursing is associated with a significant amplitude change in the newborn electroencephalogram (EEG), which wanes before the age of 3 months, and is transformed at the age of 6 months into rhythmic 3-5 Hz hedonic theta-activity. Sucking requires active physiological work, which is shown in a regular rise in heart rate. The hypothesis of a sensory-affective organization of the nascent body ego, enhanced by nursing and active sucking, seems concordant with neurophysiological phenomena related to nursing.

ABM Clinical Protocol #23: Nonpharmacological Management of Procedure-Related Pain in the Breastfeeding Infant, Revised 2016

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. These guidelines are not intended to be all-inclusive, but to provide a basic framework for physician education regarding breastfeeding.

Why do we like sweet taste: A bitter tale?

Sweet is widely considered to be one of a small number of basic or primary taste qualities. Liking for sweet tasting substances is innate, although postnatal experiences can shape responses. The power of sweet taste to induce consumption and to motivate behavior is profound, suggesting the importance of this sense for many species. Most investigators presume that the ability to identify sweet molecules through the sense of taste evolved to allow organisms to detect sources of readily available glucose from plants. Perhaps the best evidence supporting this presumption are recent discoveries in comparative biology demonstrating that species in the order Carnivora that do not consume plants also do not perceive sweet taste due to the pseudogenization of a component of the primary sweet taste receptor. However, arguing against this idea is the observation that the sweetness of a plant, or the amount of easily metabolizable sugars contained in the plant, provides little quantitative indication of the plant's energy or broadly conceived food value. Here it is suggested that the perceptual ratio of sweet taste to bitter taste (a signal for toxicity) may be a better gauge of a plant's broadly conceived food value than sweetness alone and that it is this ratio that helps guide selection or rejection of a potential plant food.

Salivary Cortisol As Indicators of Pain in Preterm Infants

Assessment and management of pain in preterm infants is critical and complicated. The addition of salivary cortisol measurement may improve the specificity of assessment and guide care to alleviate pain. The purpose of this study was fourfold: (a) assess the feasibility of a method of saliva collection in premature infants, (b) assess reliability of a method of measuring salivary cortisol in response to heelstick, (c) identify relationships between salivary cortisol and a measure of pain behavior (using CRIES) following heelstick, and (d) identify peak response times for elevations of salivary cortisol following heelstick in preterm infants. This was a prospective, descriptive pilot study. Serial saliva samples were collected from eight healthy infants 30 to 36 weeks’ gestational age in a Newborn Intensive Care Unit. Cortisol levels were determined using enzyme-immuneassay. Samples were collected without use of stimulants. Sample means supported peak and trough patterns previously described in the literature. Behavioral measures of pain did not correlate well with peak cortisol levels.

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, method of administration and safety of sucrose for relieving procedural pain in neonates as assessed by validated composite pain scores, physiological pain indicators (heart rate, respiratory rate, saturation of peripheral oxygen in the blood, transcutaneous oxygen and carbon dioxide (gas exchange measured across the skin - TcpO2, TcpCO2), near infrared spectroscopy (NIRS), electroencephalogram (EEG), or behavioural pain indicators (cry duration, proportion of time crying, proportion of time facial actions (e.g. grimace) are present), or a combination of these and long-term neurodevelopmental outcomes.

SEARCH METHODS

We used the standard methods of the Cochrane Neonatal. We performed electronic and manual literature searches in February 2016 for published randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library, Issue 1, 2016), MEDLINE (1950 to 2016), EMBASE (1980 to 2016), and CINAHL (1982 to 2016). We did not impose language restrictions.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Our main outcome measures were composite pain scores (including a combination of behavioural, physiological and contextual indicators). Secondary outcomes included separate physiological and behavioural pain indicators. We reported a mean difference (MD) or weighted MD (WMD) with 95% confidence intervals (CI) using the fixed-effect model for continuous outcome measures. For categorical data we used risk ratio (RR) and risk difference. We assessed heterogeneity by the I(2) test. We assessed the risk of bias of included trials using the Cochrane 'Risk of bias' tool, and assessed the quality of the evidence using the GRADE system.

MAIN RESULTS

Seventy-four studies enrolling 7049 infants were included. Results from only a few studies could be combined in meta-analyses and for most analyses the GRADE assessments indicated low- or moderate-quality evidence. There was high-quality evidence for the beneficial effect of sucrose (24%) with non-nutritive sucking (pacifier dipped in sucrose) or 0.5 mL of sucrose orally in preterm and term infants: Premature Infant Pain Profile (PIPP) 30 s after heel lance WMD -1.70 (95% CI -2.13 to -1.26; I(2) = 0% (no heterogeneity); 3 studies, n = 278); PIPP 60 s after heel lance WMD -2.14 (95% CI -3.34 to -0.94; I(2) = 0% (no heterogeneity; 2 studies, n = 164). There was high-quality evidence for the use of 2 mL 24% sucrose prior to venipuncture: PIPP during venipuncture WMD -2.79 (95% CI -3.76 to -1.83; I(2) = 0% (no heterogeneity; 2 groups in 1 study, n = 213); and intramuscular injections: PIPP during intramuscular injection WMD -1.05 (95% CI -1.98 to -0.12; I(2) = 0% (2 groups in 1 study, n = 232). Evidence from studies that could not be included in RevMan-analyses supported these findings. Reported adverse effects were minor and similar in the sucrose and control groups. Sucrose is not effective in reducing pain from circumcision. The effectiveness of sucrose for reducing pain/stress from other interventions such as arterial puncture, subcutaneous injection, insertion of nasogastric or orogastric tubes, bladder catherization, eye examinations and echocardiography examinations are inconclusive. Most trials indicated some benefit of sucrose use but that the evidence for other painful procedures is of lower quality as it is based on few studies of small sample sizes. The effects of sucrose on long-term neurodevelopmental outcomes are unknown.

AUTHORS' CONCLUSIONS

Sucrose is effective for reducing procedural pain from single events such as heel lance, venipuncture and intramuscular injection in both preterm and term infants. No serious side effects or harms have been documented with this intervention. We could not identify an optimal dose due to inconsistency in effective sucrose dosage among studies. Further investigation of repeated administration of sucrose in neonates is needed. There is some moderate-quality evidence that sucrose in combination with other non-pharmacological interventions such as non-nutritive sucking is more effective than sucrose alone, but more research of this and sucrose in combination with 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.

Prevention and Management of Procedural Pain in the Neonate: An Update

The prevention of pain in neonates should be the goal of all pediatricians and health care professionals who work with neonates, not only because it is ethical but also 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 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. Therefore, every health care facility caring for neonates should implement (1) a pain-prevention program that includes strategies for minimizing the number of painful procedures performed and (2) a pain assessment and management plan that includes routine assessment of pain, pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and measures for minimizing pain associated with surgery and other major procedures.

Combined non-pharmacological interventions for newborn pain relief in two degrees of pain procedures: A randomized clinical trial

BACKGROUND

Non-pharmacological interventions are effective neonatal pain reduction strategies. We aimed to study the effects of non-nutritive sucking (NNS) and swaddling on infants' behavioural and physiological parameters during shallow or deep heel stick procedures.

METHOD

In this prospective, multi-centred, randomized controlled clinical trial, we enrolled 671 newborns. The infants undergoing shallow or deep heel stick procedures were randomized into four groups: oral sucrose (routine care, group S), oral sucrose combined with NNS (group NS), oral sucrose combined with swaddling (group SS) and oral sucrose combined with NNS and swaddling (group NSS). The behavioural responses were evaluated by the Revised Neonatal Facial Coding System and the physiological signals were monitored by electrocardiogram monitors.

RESULTS

A significant synergistic analgesic effect was observed between the NS and SS groups in both the shallow (F = 5.952, p = 0.015) and deep heel stick (F = 7.452, p = 0.007) procedure. NSS group exhibited the lowest pain score. For the deep heel stick procedure, the NS group had a significantly lower increase in heart rate (HR)% and decrease in SPO2 % than the S group (F = 17.540, p = 0.000, F = 10.472, p = 0.001), while this difference was not observed in the shallow heel stick procedure. No difference was found between the S and SS groups, in terms of different physiological parameters.

CONCLUSION

Non-nutritive sucking and swaddling had synergistic effects on pain relief when used with oral sucrose. For the deep heel stick procedure, oral sucrose combined with NNS and swaddling provided the best pain relief effect. For the shallow heel stick procedure, addition of NNS and swaddling did not improve the effects.

Non-pharmacological management of infant and young child procedural pain

BACKGROUND

Infant acute pain and distress is commonplace. Infancy is a period of exponential development. Unrelieved pain and distress can have implications across the lifespan.  This is an update of a previously published review in the Cochrane Database of Systematic Reviews, Issue 10 2011 entitled 'Non-pharmacological management of infant and young child procedural pain'.

OBJECTIVES

To assess the efficacy of non-pharmacological interventions for infant and child (up to three years) acute pain, excluding kangaroo care, and music. Analyses were run separately for infant age (preterm, neonate, older) and pain response (pain reactivity, immediate pain regulation). 

SEARCH METHODS

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 2 of 12, 2015), MEDLINE-Ovid platform (March 2015), EMBASE-OVID platform (April 2011 to March 2015), PsycINFO-OVID platform (April 2011 to February 2015), and CINAHL-EBSCO platform (April 2011 to March 2015). We also searched reference lists and contacted researchers via electronic list-serves. New studies were incorporated into the review. We refined search strategies with a Cochrane-affiliated librarian. For this update, nine articles from the original 2011 review pertaining to Kangaroo Care were excluded, but 21 additional studies were added.

SELECTION CRITERIA

Participants included infants from birth to three years. Only randomised controlled trials (RCTs) or RCT cross-overs that had a no-treatment control comparison were eligible for inclusion in the analyses. However, when the additive effects of a non-pharmacological intervention could be assessed, these studies were also included. We examined studies that met all inclusion criteria except for study design (e.g. had an active control) to qualitatively contextualize results. There were 63 included articles in the current update.

DATA COLLECTION AND ANALYSIS

Study quality ratings and risk of bias were based on the Cochrane Risk of Bias Tool and GRADE approach. We analysed the standardized mean difference (SMD) using the generic inverse variance method.

MAIN RESULTS

Sixty-three studies, with 4905 participants, were analysed. The most commonly studied acute procedures were heel-sticks (32 studies) and needles (17 studies). The largest SMD for treatment improvement over control conditions on pain reactivity were: non-nutritive sucking-related interventions (neonate: SMD -1.20, 95% CI -2.01 to -0.38) and swaddling/facilitated tucking (preterm: SMD -0.89; 95% CI -1.37 to -0.40). For immediate pain regulation, the largest SMDs were: non-nutritive sucking-related interventions (preterm: SMD -0.43; 95% CI -0.63 to -0.23; neonate: SMD -0.90; 95% CI -1.54 to -0.25; older infant: SMD -1.34; 95% CI -2.14 to -0.54), swaddling/facilitated tucking (preterm: SMD -0.71; 95% CI -1.00 to -0.43), and rocking/holding (neonate: SMD -0.75; 95% CI -1.20 to -0.30). Fifty two of our 63 trials did not report adverse events. The presence of significant heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of very low quality evidence.

AUTHORS' CONCLUSIONS

There is evidence that different non-pharmacological interventions can be used with preterms, neonates, and older infants to significantly manage pain behaviors associated with acutely painful procedures. The most established evidence was for non-nutritive sucking, swaddling/facilitated tucking, and rocking/holding. All analyses reflected that more research is needed to bolster our confidence in the direction of the findings. There are significant gaps in the existing literature on non-pharmacological management of acute pain in infancy.

The sweetness and bitterness of childhood: Insights from basic research on taste preferences

In this article, we review findings from basic, experimental research on children that suggest that the liking of sweet and the dislike of bitter tastes reflect children's basic biology. Children are born preferring sweet tastes, which attract them to mother's milk and even act as an analgesic. They prefer higher levels of sweet than do adults, with preferences declining to adult levels during middle to late adolescence, which coincides with the cessation of physical growth. The level of sweetness most preferred by children has remained heightened relative to adults for nearly a decade, despite reductions in sugar, both consumed and in the food environment. In spite of these reductions, however, children's intake of sugar remains higher than that recommended by health organizations worldwide. In contrast to sweet taste, children dislike and reject bitter taste, which protects them from ingesting poisons. Although variation in bitter taste receptor genes such as TAS2R38 accounts for people's marked differences in perceptions of the same bitter-tasting compounds, basic research revealed that these genotype-phenotype relationships are modified with age, with children of the same genotype being more bitter sensitive than adults and the changeover occurring during mid-adolescence. This heightened bitter sensitivity is also evident in the taste of the foods (green vegetables) or medicines (liquid formulations of drugs) they dislike and reject. While bitter taste can be masked or blocked to varying degrees by sugars and salts, their efficacy in modulating bitterness is not only based on the type of bitter ligand but on the person's age. Children's heightened preference for sweet and dislike of bitter, though often detrimental in the modern food environment, reflects their basic biology. Increasing knowledge of individual variation in taste due to both age and genetics will shed light on potential strategies to promote healthier eating since chronic diseases derive in large part from poor food choice dictated by taste preferences, and will contribute to a new era of drug formulations designed especially for the taste palate of children.

Pharmacological and Combined Interventions to Reduce Vaccine Injection Pain in Children and Adults: Systematic Review and Meta-Analysis

BACKGROUND

This systematic review assessed the effectiveness and safety of pharmacotherapy and combined interventions for reducing vaccine injection pain in individuals across the lifespan.

DESIGN/METHODS

Electronic databases were searched for relevant randomized and quasi-randomized controlled trials. Self-reported pain and fear as well as observer-rated distress were critically important outcomes. Data were combined using standardized mean difference (SMD) or relative risk with 95% confidence intervals (CI).

RESULTS

Fifty-five studies that examined breastfeeding (which combines sweet-tasting solution, holding, and sucking), topical anesthetics, sweet-tasting solutions (sucrose, glucose), vapocoolants, oral analgesics, and combination of 2 versus 1 intervention were included. The following results report findings of analyses of critical outcomes with the largest number of participants. Compared with control, acute distress was lower for infants breastfed: (1) during vaccination (n=792): SMD -1.78 (CI, -2.35, -1.22) and (2) before vaccination (n=100): SMD -1.43 (CI, -2.14, -0.72). Compared with control/placebo, topical anesthetics showed benefit on acute distress in children (n=1424): SMD -0.91 (CI, -1.36, -0.47) and self-reported pain in adults (n=60): SMD -0.85 (CI, -1.38, -0.32). Acute and recovery distress was lower for children who received sucrose (n=2071): SMD -0.76 (CI, -1.19, -0.34) or glucose (n=818): SMD -0.69 (CI, -1.03, -0.35) compared with placebo/no treatment. Vapocoolants reduced acute pain in adults [(n=185), SMD -0.78 (CI, -1.08, -0.48)] but not children. Evidence from other needle procedures showed no benefit of acetaminophen or ibuprofen. The administration of topical anesthetics before and breastfeeding during vaccine injections showed mixed results when compared with topical anesthetics alone. There were no additive benefits of combining glucose and non-nutritive sucking (pacifier) compared with glucose or non-nutritive sucking (pacifier) alone or breastfeeding and sucrose compared with breastfeeding or sucrose alone.

CONCLUSIONS

Breastfeeding, topical anesthetics, sweet-tasting solutions, and combination of topical anesthetics and breastfeeding demonstrated evidence of benefit for reducing vaccine injection pain in infants and children. In adults, limited data demonstrate some benefit of topical anesthetics and vapocoolants.

Ewes Direct Most Maternal Attention towards Lambs that Show the Greatest Pain-Related Behavioural Responses

Although neonatal farm animals are frequently subjected to painful management procedures, the role of maternal behaviour in pain coping, has not been much studied. We investigated whether ewes were able to distinguish between lambs in pain and those that were not, and whether their behaviour altered depending on the severity of lamb pain. Eighty male lambs were allocated to one of 4 pain treatments within 24 hours of birth. Lambs were either handled only (C), bilaterally castrated with tight rubber rings (RR), as for RR but with the application of a Burdizzo clamp immediately proximal to the ring (Combined) or subjected to short scrotum castration (SSC) where the testicles were retained within the abdomen and only the scrotum removed. The behaviour of the ewe, treated lamb and untreated sibling where present (n = 54) were recorded for 30 minutes after treatment. Castration treatment increased the expression of abnormal standing and lying postures, specific pain-related behaviours (head-turning, stamping/kicking, easing quarters, tail wagging) and composite pain scores (P<0.001 for all). The greatest expression of pain-related behaviours was shown by lambs in the RR group, which were the only group to show rolling responses indicative of severe pain, followed by the SSC group. Ewes expressed more licking/sniffing responses to the RR and SSC lambs than towards the Combined and C lambs (P<0.05), and oriented most to RR lambs and least to C lambs (P<0.001). Ewes with two lambs also directed more attention towards the treated than the untreated lamb (P<0.001). The quantity of maternal care directed towards the lamb was positively correlated with the expression of active pain behaviours. The data demonstrate that ewes are able to discriminate between lambs in pain and those that are not, and that their response is increased with a greater severity of pain.

[Non-pharmaceutical measures, topical analgesics and oral administration of glucose in pain management: Austrian interdisciplinary recommendations on pediatric perioperative pain management]

Non-pharmaceutical procedures are increasingly being used in pediatric pain therapy in addition to pharmaceutical procedures and have a supporting function. This article describes the non-pharmaceutical procedures which have an influence on perioperative and posttraumatic pain in children and adolescents. Prerequisites for every adequate pain therapy are affection, imparting a feeling of security, distraction and the creation of a child-oriented environment. Topical analgesics are indicated for application to intact skin for surface anesthesia. For a safe use consideration must be given to the duration of application, the dose and the maximum area of skin treated in an age-dependent manner. For simple but painful procedures in premature infants, neonates and infants, pain can be effectively reduced by the oral administration of glucose. The positive effect is guaranteed particularly for the use in a once only pain stimulation. Non-nutritive sucking, swaddling, facilitated tucking and kangaroo mother care, for example can be used as supportive measures during slightly painful procedures. There is insufficient evidence for a pain reducing effect in older infants and small children. Physical therapeutic procedures can be used as accompanying measures for acute pain and are individually adapted. However, the limited amount of currently available data is insufficient to make a critical scientific assessment of the individual measures. The effects can, however, be observed in the daily routine practice. Psychological methods can facilitate coping with pain. In situations with mental and psychiatric comorbidities or psychosocial impairment, a psychologist should be consulted. Acupuncture and hypnosis are also a meaningful addition within the framework of multimodal pain therapy.

Interventions for the cessation of non-nutritive sucking habits in children

BACKGROUND

Comforting behaviours, such as the use of pacifiers (dummies, soothers), blankets and finger or thumb sucking, are common in babies and young children. These comforting habits, which can be referred to collectively as 'non-nutritive sucking habits' (NNSHs), tend to stop as children get older, under their own impetus or with support from parents and carers. However, if the habit continues whilst the permanent dentition is becoming established, it can contribute to, or cause, development of a malocclusion (abnormal bite). A diverse variety of approaches has been used to help children with stopping a NNSH. These include advice, removal of the comforting object, fitting an orthodontic appliance to interfere with the habit, application of an aversive taste to the digit or behaviour modification techniques. Some of these interventions are easier to apply than others and less disturbing for the child and their parent; some are more applicable to a particular type of habit. 

OBJECTIVES

The primary objective of the review was to evaluate the effects of different interventions for cessation of NNSHs in children. The secondary objectives were to determine which interventions work most quickly and are the most effective in terms of child and parent- or carer-centred outcomes of least discomfort and psychological distress from the intervention, as well as the dental measures of malocclusion (reduction in anterior open bite, overjet and correction of posterior crossbite) and cost-effectiveness.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 8 October 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 9), MEDLINE via OVID (1946 to 8 October 2014), EMBASE via OVID (1980 to 8 October 2014), PsycINFO via OVID (1980 to 8 October 2014) and CINAHL via EBSCO (1937 to 8 October 2014), the US National Institutes of Health Trials Register (Clinical Trials.gov) (to 8 October 2014) and the WHO International Clinical Trials Registry Platform (to 8 October 2014). There were no restrictions regarding language or date of publication in the searches of the electronic databases. We screened reference lists from relevant articles and contacted authors of eligible studies for further information where necessary.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in children with a non-nutritive sucking habit that compared one intervention with another intervention or a no-intervention control group. The primary outcome of interest was cessation of the habit.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration. Three review authors were involved in screening the records identified; two undertook data extraction, two assessed risk of bias and two assessed overall quality of the evidence base. Most of the data could not be combined and only one meta-analysis could be carried out.

MAIN RESULTS

We included six trials, which recruited 252 children (aged two and a half to 18 years), but presented follow-up data on only 246 children. Digit sucking was the only NNSH assessed in the studies. Five studies compared single or multiple interventions with a no-intervention or waiting list control group and one study made a head-to-head comparison. All the studies were at high risk of bias due to major limitations in methodology and reporting. There were small numbers of participants in the studies (20 to 38 participants per study) and follow-up times ranged from one to 36 months. Short-term outcomes were observed under one year post intervention and long-term outcomes were observed at one year or more post intervention. Orthodontics appliance (with or without psychological intervention) versus no treatmentTwo trials that assessed this comparison evaluated our primary outcome of cessation of habit. One of the trials evaluated palatal crib and one used a mix of palatal cribs and arches. Both trials were at high risk of bias. The orthodontic appliance was more likely to stop digit sucking than no treatment, whether it was used over the short term (risk ratio (RR) 6.53, 95% confidence interval (CI) 1.67 to 25.53; two trials, 70 participants) or long term (RR 5.81, 95% CI 1.49 to 22.66; one trial, 37 participants) or used in combination with a psychological intervention (RR 6.36, 95% CI 0.97 to 41.96; one trial, 32 participants). Psychological intervention versus no treatmentTwo trials (78 participants) at high risk of bias evaluated positive reinforcement (alone or in combination with gaining the child's co-operation) or negative reinforcement compared with no treatment. Pooling of data showed a statistically significant difference in favour of the psychological interventions in the short term (RR 6.16, 95% CI 1.18 to 32.10; I(2) = 0%). One study, with data from 57 participants, reported on the long-term effect of positive and negative reinforcement on sucking cessation and found a statistically significant difference in favour of the psychological interventions (RR 6.25, 95% CI 1.65 to 23.65). Head-to-head comparisonsOnly one trial demonstrated a clear difference in effectiveness between different active interventions. This trial, which had only 22 participants, found a higher likelihood of cessation of habit with palatal crib than palatal arch (RR 0.13, 95% CI 0.03 to 0.59).

AUTHORS' CONCLUSIONS

This review found low quality evidence that orthodontic appliances (palatal arch and palatal crib) and psychological interventions (including positive and negative reinforcement) are effective at improving sucking cessation in children. There is very low quality evidence that palatal crib is more effective than palatal arch. This review has highlighted the need for high quality trials evaluating interventions to stop non-nutritive sucking habits to be conducted and the need for a consolidated, standardised approach to reporting outcomes in these trials.

Energy conservation in infants

Energy acquisition through suckling has been widely studied in rat and human infants. Processes mediating energy conservation, however, have not received the attention that they deserve. This essay, in honor of Professor Jerry Hogan, discusses parallel behaviors used by rat and human mothers to minimize energy loss in their offspring. Parallel mechanisms underlying energy preservation have been identified in rats and humans, suggesting phylogenetic conservation and possibly continuity. This article is part of a Special Issue entitled: In Honor of Jerry Hogan.

Oral glucose solution to alleviate pain induced by intramuscular injections in preterm infants

PURPOSE

The purpose was to assess the effectiveness of 5% oral glucose solution in reducing pain in preterm infants during intramuscular injection.

DESIGN AND METHODS

We conducted a prospective, randomized, controlled, unblinded trial to investigate the effect of glucose solution on the pain of intramuscular injection in preterm infants (N = 80).

RESULTS

Infants who received oral glucose had significantly lower pain scores (p < .001), less crying time (p < .001), higher oxygen saturation (p < .001), and lower heart rate after compared with during the procedure (p = .02).

PRACTICE IMPLICATIONS

Our results suggest that oral glucose, even if used in the lowest dose, may have a pain-relieving effect in preterm infants if administered pre-procedure.

Cerebral hemodynamic changes and pain perception during venipuncture: is glucose really effective?

Newborns are exposed to a considerable number of painful stimuli. This study is aimed to investigate the effects of 30% glucose solution and nonnutritive sucking on pain perception during venipuncture. Twenty-five term infants were randomized as receiving 30% dextrose (group 1) or sterile water (group 2). Neonatal Infant Pain Scale scores, skin conductance algesimeter recordings, and near-infrared spectroscopy measurements were recorded during the procedure. Neonatal Infant Pain Scale and skin conductance algesimeter results were decreased in both groups from that during venipuncture to after the procedure. Group 1 had lower Neonatal Infant Pain Scale scores compared with group 2 after venipuncture, different from the skin conductance algesimeter, where no difference was observed between groups. In group 1, cerebral blood volume increased after venipuncture. Glucose does not attenuate the Neonatal Infant Pain Scale score and skin conductance algesimeter index during venipuncture, but it leads to a lower Neonatal Infant Pain Scale score after venipuncture unlike the skin conductance algesimeter index, which was not lowered.

Ontogeny of taste preferences: basic biology and implications for health

Health initiatives address childhood obesity in part by encouraging good nutrition early in life. This review highlights the science that shows that children naturally prefer higher levels of sweet and salty tastes and reject lower levels of bitter tastes than do adults. Thus, their basic biology does not predispose them to favor the recommended low-sugar, low-sodium, vegetable-rich diets and makes them especially vulnerable to our current food environment of foods high in salt and refined sugars. The good news is that sensory experiences, beginning early in life, can shape preferences. Mothers who consume diets rich in healthy foods can get children off to a good start because flavors are transmitted from the maternal diet to amniotic fluid and mother's milk, and breastfed infants are more accepting of these flavors. In contrast, infants fed formula learn to prefer its unique flavor profile and may have more difficulty initially accepting flavors not found in formula, such as those of fruit and vegetables. Regardless of early feeding mode, infants can learn through repeated exposure and dietary variety if caregivers focus on the child's willingness to consume a food and not just the facial expressions made during feeding. In addition, providing complementary foods low in salt and sugars may help protect the developing child from excess intake later in life. Early-life experiences with healthy tastes and flavors may go a long way toward promoting healthy eating, which could have a significant impact in addressing the many chronic illnesses associated with poor food choice.

Oral sucrose and non-nutritive sucking goes some way to reducing pain during retinopathy of prematurity eye examinations

AIM

To evaluate the efficacy of oral sucrose combined with non-nutritive sucking for reducing pain associated with retinopathy of prematurity screening.

METHODS

This was a randomised controlled study of 64 infants undergoing eye examination for retinopathy of prematurity screening. Topical anaesthetic (Proparacaine; Alcaine(®) drop 0.5%: ALCON CANADA Inc., Mississauga, Canada) was applied 30 sec before the eye examination in all infants. The infants in intervention group (Group 1, n = 32) received 0.5 mL/kg of 24% sucrose with a pacifier. The control group (Group 2, n = 32) received 0.5 mL/kg of sterile water with a pacifier.

RESULTS

The groups had similar gestational ages (28.5 ± 2.8 weeks), mean birthweight (1304 ± 466 g) or corrected gestational age (35.4 ± 3.7 weeks) at examination. The intervention group had a significantly lower mean Premature Infant Pain Profile score during examination of the first eye, following insertion of the speculum (Group 1:13.7 ± 2.1 vs. Group 2:16.4 ± 1.8, p = 0.001).

CONCLUSION

Although sucrose combined with non-nutritive sucking modestly reduces pain scores during eye examinations, there is need to further studies to explore significant pain relief for infants undergoing retinopathy of prematurity screening.

Effects of gustatory nerve transection and/or ovariectomy on oral capsaicin avoidance in rats

The incidence of chronic oral pain such as burning mouth syndrome is greater in peri-menopausal females, and was postulated to be associated with gustatory nerve damage. We investigated whether bilateral transection of the chorda tympani, with or without accompanying ovariectomy, affected oral capsaicin avoidance in rats. Female rats had restricted access to 2 bottles, 1 bottle containing capsaicin (concentration range: 0.33-33 μM/L) and the other vehicle. Percent volume of capsaicin consumption and lick counts were measured. The concentration series was tested before and 0.5, 3, 6, 9, and 12 months after the following surgical procedures: (a) bilateral transection of the chorda tympani (CTx); (b) ovariectomy (OVx); (3) CTx plus OVx; or (4) sham CT surgery. Before surgery there was a concentration-dependent decrease in licks and volume of capsaicin consumed, with a threshold between 0.1 and 0.3 ppm. The majority of drink licks occurred during the first 9 minutes of access. Over the 12-month test period, the CTx group did not exhibit reduced capsaicin consumption, and consumed significantly more capsaicin at 6 and 9 months postsurgery. Rats in the OVx group consistently consumed significantly less capsaicin and exhibited significantly higher counts of capsaicin-evoked Fos-like immunoreactivity in the dorsomedial trigeminal subnucleus caudalis (Vc) compared to all other treatment groups. That CTx, with or without OVx, did not enhance capsaicin avoidance indicates that damage to the gustatory system does not disinhibit trigeminal nociceptive transmission.

Pain management in neonates

Multiple lines of evidence suggest an increased sensitivity to pain in neonates. Repeated and prolonged pain exposure may affect the subsequent development of pain systems, as well as potentially contribute to alterations in long-term development and behavior. Despite impressive gains in the knowledge of neonatal pain mechanisms and strategies to treat neonatal pain acquired during the last 15 years, a large gap still exists between routine clinical practice and research results. Accurate assessment of pain is crucial for effective pain management in neonates. Neonatal pain management should rely on current scientific evidence more than the attitudes and beliefs of care-givers. Parents should be informed of pain relief strategies and their participation in the health care plan to alleviate pain should be encouraged. The need for systemic analgesia for both moderate and severe pain, in conjunction with behavioral/environmental approaches to pain management, is emphasized. A main sources of pain in the neonate is procedural pain which should always be prevented and treated. Nonpharmacological approaches constitute important treatment options for managing procedural pain. Nonpharmacological interventions (environmental and preventive measures, non-nutritive sucking, sweet solutions, skin-skin contact, and breastfeeding analgesia) can reduce neonatal pain indirectly by reducing the total amount of noxious stimuli to which infants are exposed, and directly, by blocking nociceptive transduction or transmission or by activation of descending inhibitory pathways or by activating attention and arousal systems that modulate pain. Opioids are the mainstay of pharmacological pain treatment but there are other useful medications and techniques that may be used for pain relief. National guidelines are necessary to improve neonatal pain management at the institutional level, individual neonatal intensive care units need to develop specific practice guidelines regarding pain treatment to ensure that all staff are familiar with the effects of the drugs being used and to guarantee access and safe administration of pain treatment to all neonates.

Breastfeeding and pain relief in full-term neonates during immunization injections: a clinical randomized trial

Background

The aim of this study was to examine the effect of breastfeeding on pain relief in full-term neonates during injection of hepatitis B vaccine.

Methods

This was a randomized clinical trial. A sample of full-term neonates was randomly allocated into two groups: the experimental group and the control group. Neonates in the experimental group were breastfed two minutes before, during, and after the hepatitis B immunization and the control group were held in mothers’ arms but not fed. Pain was assessed using the Douleur Aiguë du Nouveau-né (DAN) scale measuring facial expressions, limb movements and vocal expressions. The assessments were carried out after hepatitis B immunization.

Results

One hundred thirty healthy full-term neonates were studied (65 in the experimental group and 65 in the control group). Gestational age, birth weight, Apgar score and gender did not differ between the two groups. The mean total pain score as measured by the DAN scale was 3.52 (SD = 1.37) for the experimental group and it was 6.78 (SD = 1.69) for the controls indicating a significant lower pain score for the experimental group (P<0.001). Also, there were significant differences for the three measures of DAN scale that are facial expressions, limb movements and vocal expression, between the two study groups (P<0.001).

Conclusion

The findings confirm that breastfeeding reduces pain and is effective way for pain relief during hepatitis B vaccine injection.

Trial registration

IRCT201104166206N1

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.

Paradoxical surrogate markers of dental injury-induced pain in the mouse

Dental pain, including toothache, is one of the most prevalent types of orofacial pain, causing severe, persistent pain that has a significant negative effect on quality of life, including eating disturbances, mood changes, and sleep disruption. As the primary cause of toothache pain is injury to the uniquely innervated dental pulp, rodent models of this injury provide the opportunity to study neurobiological mechanisms of tissue injury-induced persistent pain. Here we evaluated behavioral changes in mice with a dental pulp injury (DPI) produced by mechanically exposing the pulp to the oral environment. We monitored the daily life behaviors of mice with DPI, including measures of eating, drinking, and movement. During the first 48 hours, the only parameter affected by DPI was locomotion, which was reduced. There was also a significant short-term decrease in the amount of weight gained by DPI animals that was not related to food consumption. As cold allodynia is frequently observed in individuals experiencing toothache pain, we tested whether mice with DPI demonstrate an aversion to drinking cold liquids using a cold-sucrose consumption test. Surprisingly, mice with DPI increased their consumption of sucrose solution, to over 150% of baseline, regardless of temperature. Both the weight loss and increased sucrose intake in the first 2 days of injury were reversed by administration of indomethacin. These findings indicate that enhanced sucrose consumption may be a reliable measure of orofacial pain in rodents, and suggest that alterations in energy expenditure and motivational behaviors are under-recognized outcomes of tooth injury.

The combined use of sucrose and nonnutritive sucking for procedural pain in both term and preterm neonates: an integrative review of the literature

Many agents, both pharmacologic and nonpharmacologic, have been studied to alleviate neonatal pain, and the research is extensive. The 2 most commonly studied nonpharmacologic agents studied have been sucrose and nonnutritive sucking (NNS). There is increasing evidence that the synergistic effect of sucrose and NNS is more effective than the effect of sucrose or NNS alone. The purpose of this integrative review of the literature was to determine whether there is a relationship between the synergistic effect of combining sucrose and NNS administered before and during painful procedures, and reducing procedural pain in both preterm and term neonates. This integrative review indicates that the combination of sucrose and NNS is a safe, effective, and clinically significant means of providing procedural pain relief in neonates, both term and preterm.

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.

Sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age

BACKGROUND

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

OBJECTIVES

To determine the effectiveness of sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age compared with no treatment, placebo, other sweet-tasting solutions, or pharmacological or other non-pharmacological pain-relieving methods.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012); MEDLINE via Ovid (1966 to 2012); CINAHL via OVID (1982 to 2012). The World Health Organization International Clinical Trials Registry Platform was also searched for any ongoing trials. Clinical trial registries, conference proceedings and references for randomised controlled trials (RCTs) were also searched. An updated search was run to capture any new publications before finalising the review in April 2012 and no new included studies were identified. Two review authors (MK & JF) independently abstracted data and assessed quality using a standard form. Authors have been contacted for missing data.

SELECTION CRITERIA

Randomised-controlled trials using a sweet-tasting solution to treat pain in healthy term infants (gestational age 37 weeks and over), between one month and 12 months of age who required needle-related procedures. These procedures included but were not limited to: subcutaneous or intramuscular injections, venepuncture, and heel lance. Studies in which the painful procedure was circumcision, lumbar puncture or supra-pubic bladder aspiration were not included as they are more severe and painful than needle-related procedures. Control conditions included no treatment or placebo (water) or any other identical intervention (same appearance and consistency) without active ingredient, another sweet-tasting solution, a pharmacological pain-relieving method (e.g. paracetamol, topical anaesthetic cream), non-pharmacological pain-relieving method (e.g. distraction method, non-nutritive sucking).

DATA COLLECTION AND ANALYSIS

Assessment of trial quality, data extraction and synthesis of data were performed using standard methods of the Cochrane Pain, Palliative and Supportive Care Group. We report mean differences (MD) with 95% confidence intervals (CI) using fixed-effect models as appropriate for continuous outcome measures. We planned to report risk ratio (RR) and risk difference (RD) for dichotomous outcomes. The Chi(2) test and I(2) statistic were used to assess between-study heterogeneity.

MAIN RESULTS

Sixty-five (65) studies were identified for possible inclusion in this review. Fourteen published RCTs with a total of 1551 participants met the inclusion criteria. Duration of cry was significantly reduced in infants who were administered a sweet-tasting solution [MD -13.47 (95% CI -16.80 to -10.15)], P < 0.00001 compared with water. However, there was considerable heterogeneity between the studies (I(2) = 94%) that we were unable to explain. Meta-analysis was not able to be undertaken for any of the other outcome measures, except for cry duration, because of differences in study design. However, most of the individual studies that measured pain found sucrose to significantly reduce pain compared with the control group. One study compared sucrose and Lidocaine-prilocaine cream and no significant difference was found between the two treatments for the outcomes pain and cry duration. Due to the differences between the studies, we were unable to identify the optimal concentration, volume or method of administration of sweet-tasting solutions in infants aged one to 12 months. Further large RCTs are needed.

AUTHORS' CONCLUSIONS

There is insufficient evidence to confidently judge the effectiveness of sweet-tasting solutions in reducing needle-related pain in infants (one month to 12 months of age). The treatments do, however, appear promising. Data from a series of individual trials are promising, as are the results from a subset meta-analysis of studies measuring duration of crying. Further well controlled RCTs are warranted in this population to determine the optimal concentration, volume, method of administration, and possible adverse effects.

The challenges of neonatal magnetic resonance imaging

Improved neonatal survival rates and antenatal diagnostic imaging is generating a growing demand for postnatal MRI examinations. Neonatal brain MRI is now becoming standard clinical care in many settings, but with the exception of some research centres, the technique has not been optimised for imaging neonates and small children. Here, we review some of the challenges involved in neonatal MRI, including recent advances in overall MR practicality and nursing practice, to address some of the ways in which the MR experience could be made more neonate-friendly.

Oral sucrose for pain control in nonneonate infants during minor painful procedures

PURPOSE

To provide information regarding the effective use of oral sucrose as an analgesic for immunization and venipuncture procedures in the older infant.

DATA SOURCES

Evidence-based literature including original clinical trials, reviews, and clinical practice guidelines.

CONCLUSIONS

Most infants are exposed to multiple minor painful procedures during the first year of life. Oral sucrose solution in a 24% concentration at a dose of 2 mL approximately 2 min prior to the painful procedure has been shown effective in reducing pain during immunizations and venipuncture in the outpatient setting in infants aged 1-12 months old.

IMPLICATIONS FOR PRACTICE

Oral sucrose solution should be used as a pain reduction intervention in infants up to 12 months of age undergoing minor painful procedures. Its proven effectiveness as an analgesic, low rate of minor adverse events, ease of administration, and excellent availability make sucrose a good choice for this purpose. Additional research is needed regarding dose response in different infant age groups, optimal concentration of sucrose solution, need for multiple sucrose dosing, adjustment for multiple painful procedures, and addition of optimal nonpharmacologic interventions as a combination approach.

Warmth is analgesic in healthy newborns

This study identifies a behavioral and nonpharmacologic means of preventing and reducing newborn pain. Our objective was to determine whether warmth is analgesic in newborn infants undergoing vaccination-a routine painful hospital procedure. We used a prospective randomized controlled trial of 47 healthy full-term newborn infants. Infants were randomized into 1 of 3 conditions prior to vaccination: warmth exposure, pacifier suckling, or sucrose taste. Crying, grimacing, and heart rate differences were analyzed between groups before, during, and after vaccination as outcome measures. Warmer infants cried significantly less than sucrose taste or pacifier suckling after vaccination. Heart rate patterns reflected this analgesia. Core temperature did not differ between study groups. Providing natural warmth to newborn infants during a painful procedure decreases the crying and grimacing on par with the "gold" standard treatments of sucrose or pacifier.

A NEONATAL FACIAL IMAGE SCORING SYSTEM (NFISS) FOR PAIN RESPONSE STUDIES

The aim of this study was to establish a scoring system, Neonatal Facial Image Scoring System (NFISS), for investigating the pain responses in neonates during routine venipuncture. We collected 1998 facial images from 19 infants during the first phase of this study and identified twelve features of the facial image: normalized scale for NFISS (scale from 0-15), including brow bulge (0-2), vertical brow furrowing (0-1) and short distance (0-1), brow lowering (0-1), eyes close (0-1), bulging eyes (0-2), eye-eye furrowing (0-1), cheek bulge (0-1), nasal-labial furrowing (0-2), mouth open and stretch (0-1), lip purse (0-1) and taut tongue (0-1). During the second evaluation phase, with 2770 images from 31 newborn infants (average age: 2.85°”.027 days), the pain responses were graded on the NFISS scale. Two peak score values during a time course of baseline-venipuncture-recovery (3-3-10 min) were found with needle piercing and needle withdrawal. The reliability of the score analysis was evaluated using 492 randomly selected images out of the 2770 images. The results for intra-scorer (author, one week interval) and inter-scorer (author and one experienced nurse) has correlation coefficients of 0.916 and 0.826, respectively.

Analgesic effect of breast milk versus sucrose for analgesia during heel lance in late preterm infants

OBJECTIVE

The purpose of this trial was to investigate whether breast milk (either breastfed or bottle-fed) has a better analgesic effect than sucrose in newborns born at a postmenstrual age between 32 and 37 weeks.

METHODS

We conducted a randomized controlled trial at a secondary care neonatal unit in the Netherlands on 71 preterm neonates (postmenstrual age at birth 32-37 weeks), undergoing heel lance with an automated piercing device. Newborns were randomly assigned to breast milk (either breastfed or bottle-fed) administered during heel lance or oral sucrose administered before heel lance. We assessed the Premature Infant Pain Profile (PIPP) score (range, 0-21) to investigate whether there was a difference in pain score between neonates receiving breast milk and those receiving sucrose solution.

RESULTS

There was no significant difference in mean PIPP score between neonates receiving breast milk (6.1) and those receiving sucrose (5.5), with a mean difference of 0.6 (95% confidence interval -1.6 to 2.8; P = .58).

CONCLUSIONS

From this study, it cannot be concluded that breast milk has a better analgesic effect than sucrose in late preterm infants. From the results, it follows with 95% confidence that the analgesic effect of breast milk is not >1.6 points better and not > 2.8 points worse on the PIPP scale (SD 3.7) than the analgesic effect of sucrose in late preterm infants.

The role of social isolation in ethanol effects on the preweanling rat

The present experiments investigated the effects of acute ethanol exposure on voluntary intake of 0.1% saccharin or water as well as behavioral and nociceptive reactivity in 12-day-old (P12) rats exposed to differing levels of isolation. The effects of ethanol emerged only during short-term social isolation (STSI) with different patterns observed in males and females and in pups exposed to saccharin or water. The 0.5g/kg ethanol dose selectively increased saccharin intake in females, decreased rearing activity in males and attenuated isolation-induced analgesia (IIA) in all water-exposed pups. Ingestion of saccharin decreased IIA, and the 0.5g/kg ethanol dose further reduced IIA. The 1.0g/kg ethanol dose, administered either intragastrically or intraparentionally, also decreased IIA in P12 females, but not in P9 pups. A significant correlation between voluntary saccharin intake and baseline nociceptive reactivity was revealed in saline injected animals, saccharin intake was inversely correlated with behavioral activation and latency of reaction to noxious heat after 0.5g/kg ethanol in females. The 0.5g/kg ethanol dose did not affect plasma corticosterone (CORT) measured 5h after maternal separation or 20min after ethanol injection. Female pups CORT level was inversely correlated with magnitude of IIA that accompanied the first episode of STSI (pretest isolation) 1.5-2h before CORT measurement. The present findings suggest that the anxiolytic properties of ethanol are responsible for enhancement of saccharin intake during STSI. Furthermore, differential reactivity of P12 males and females to STSI plays an important role in ethanol effects observed at this age.

Oral sucrose and "facilitated tucking" for repeated pain relief in preterms: a randomized controlled trial

OBJECTIVES

To test the comparative effectiveness of 2 nonpharmacologic pain-relieving interventions administered alone or in combination across time for repeated heel sticks in preterm infants.

METHODS

A multicenter randomized controlled trial in 3 NICUs in Switzerland compared the effectiveness of oral sucrose, facilitated tucking (FT), and a combination of both interventions in preterm infants between 24 and 32 weeks of gestation. Data were collected during the first 14 days of their NICU stay. Three phases (baseline, heel stick, recovery) of 5 heel stick procedures were videotaped for each infant. Four independent experienced nurses blinded to the heel stick phase rated 1055 video sequences presented in random order by using the Bernese Pain Scale for Neonates, a validated pain tool.

RESULTS

Seventy-one infants were included in the study. Interrater reliability was high for the total Bernese Pain Scale for Neonates score (Cronbach's α: 0.90-0.95). FT alone was significantly less effective in relieving repeated procedural pain (P < .002) than sucrose (0.2 mL/kg). FT in combination with sucrose seemed to have added value in the recovery phase with lower pain scores (P = .003) compared with both the single-treatment groups. There were no significant differences in pain responses across gestational ages.

CONCLUSIONS

Sucrose with and without FT had pain-relieving effects even in preterm infants of <32 weeks of gestation having repeated pain exposures. These interventions remained effective during repeated heel sticks across time. FT was not as effective and cannot be recommended as a nonpharmacologic pain relief intervention for repeated pain exposure.