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

Evaluating Effectiveness of the Use of an Extremity Stabilization Device for Vascular Access Procedures in Pediatrics

The purpose of this study is to evaluate the effectiveness of SafeBoard, a Food and Drug Administration-approved extremity stabilization device, as an assistive method in performing peripherally inserted central catheter procedures on children 0 to 3 years of age. This is a retrospective chart review ( n  = 59) of vascular access procedures where SafeBoard was utilized ( n  = 32 ) in comparison to those procedures which utilized a traditional approach to placement ( n  = 27). Statistical analysis demonstrated significant effect on length of procedure time, number of personnel needed for procedure, and success of placement when SafeBoard was utilized. Obtaining vascular access in pediatrics can be a challenging endeavor. Most young pediatric patients require procedural sedation and/or assistive personnel as a "holder" for successful vascular access placement to occur. An alternative option for extremity stabilization may provide improved workflow and improved placement success, which in turn may positively affect workflow.

Oral Sucrose in Infants Undergoing Flexible Nasolaryngoscopy: A Blinded Randomized Pilot Study

INTRODUCTION

Flexible nasolaryngoscopy (FNL) is a common, uncomfortable procedure performed to assess the upper airway in infants. Oral sucrose is used during various painful procedures in infants but has not been used during FNL. Our objective was to understand the impact of oral sucrose on discomfort in infants undergoing FNL.

METHODS

Infants (<12-months-old) undergoing FNL in the otolaryngology clinic were randomized to treatment (0.5 mL 24% oral sucrose) or standard management (no sucrose). Sucrose was administered <2 min prior to FNL performed by a single endoscopist. Outcome measures included: EVENDOL pain scale and cry duration and visit duration. Infant discomfort was measured by a second observer who was blinded to treatment group.

RESULTS

Forty-seven infants were included, 23 were treated with sucrose and 24 with standard management. The median (IQR) age was 3.0 (2-5.7) months. There were no significant differences in age, weight, or sex across groups. The median (IQR) duration of FNL was 35.2 (26.5-58.4) and 36.4 (28.9-51.8) seconds for treatment and standard management groups, respectively. Mean (SD) EVENDOL scores were significantly lower in the sucrose group [4.9 (2.0)] than standard group (6.7 [2.1]) (p = 0.003). Mean cry duration after FNL was significantly shorter in the sucrose group (29.9 [20.4] seconds) than the standard group (52.7.0 [40.6] seconds) (p = 0.02). Median (IQR) visit duration did not differ across groups (1.1 [0.9-1.3] vs. 1.1 [0.7-1.4] h [p = 0.15]).

CONCLUSION

Oral sucrose given before FNL reduced EVENDOL scores and cry duration after FNL and did not prolong clinic visits in this randomized pilot study.

LEVEL OF EVIDENCE

2 Laryngoscope, 2024.

[Evidence-based guideline for neonatal pain management in China (2023)]

Pain disrupts neonatal vital signs and internal environment homeostasis and affects the recovery process, and recurrent pain stimulation is one of the important risk factors for neurodevelopmental disorders and some chronic diseases. In order to standardize pain management practice in neonatal wards in China and effectively prevent and reduce the adverse effects of pain on the physical and mental development of neonates, National Clinical Research Center for Child Health and Diseases (Children's Hospital of Chongqing Medical University) convened a multidisciplinary panel to formulate the evidence-based guideline for neonatal pain management in China (2023 edition) following the principles and methods for the guideline development issued by the World Health Organization. Based on the best evidence and expert consensus, this guideline gives 26 recommendations for nine clinical issues, i.e., the classification and definition of neonatal pain, common sources of pain, pain assessment principles, pain assessment methods, analgesic principle, non-pharmaceutical analgesic methods, pharmaceutical analgesic methods, parental participation in pain management, and recording methods for pain management, so as to provide medical staff with guidance and a decision-making basis for neonatal pain assessment and analgesia management.

Improving Consistency in the Use of Sucrose With Comfort Measures During Minor Painful Procedures

BACKGROUND

Inconsistent pain management practices can have negative physiologic and neurodevelopmental consequences in the neonate. Low rates of oral sucrose use with comfort measures for pain management during minor painful procedures were identified at a level III neonatal intensive care unit. Underutilization of pain management resources occurs despite the availability of evidence-based pain management interventions.

PURPOSE

To improve consistency in the use of oral sucrose solution with comfort measures during peripheral intravenous catheter insertion attempts in the neonatal intensive care unit in patients greater than or equal to 32 0/7th weeks postmenstrual age.

METHODS

Quality improvement methods were used to implement an evidence-based procedural pain algorithm for minor painful procedures and optimize pain management processes over a 15-week period in a 26-bed, level III neonatal intensive care unit.

RESULTS

There was an increase in the average percentage of documented use of sucrose with comfort measures during peripheral intravenous catheter insertion attempts from 20% to 27%. There was a 41% increase in the average presence of a sucrose order indicated for procedural pain. There were improvements in staff knowledge of sucrose dosing and perceived behavior of staff after completing the education.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Procedural pain management should be used as a quality indicator and guidelines should be established with the support of key stakeholders in neonatal intensive care settings. Future projects should address barriers related to workflow and accessibility of sucrose, include other common needlestick procedures, and expand the role of parent participation in pain management practices.Video Abstract available at:https://journals.lww.com/advancesinneonatalcare/pages/video.aspx?v=60 .

The effectiveness of massage interventions on procedural pain in neonates: A systematic review and meta-analysis

BACKGROUND

The painful procedures experienced by neonates during hospitalization have short-term or long-term effects on neonates. While the limitations of previous interventions make it imperative to explore effective interventions that are readily available. This systematic review and meta-analysis was conducted to evaluate the safety and effectiveness of massage for pain management in neonates.

METHODS

This systematic review was registered in PROSPER. PubMed, Embase, Cochrane Library, and the Clinical Trials Registry were searched to December 2021. Two reviewers independently carried out study selection, data extraction, bias risk assessment. Continuous data were analyzed by mean differences (MD). Dichotomous data were reported using relative risk. If at least two studies reported identical results by the same pain assessment tool, a meta-analysis was conducted using random effect model and inverse variance.

RESULTS

Total 11 included studies involving 755 neonates investigated the effects of massage on neonatal pain response compared to standard care. The meta-analysis showed that massage could effectively improve pain response in neonates compared to standard care no matter whether neonatal infant pain scale (NIPS) or premature infant pain profile (PIPP) was used as an assessment tool. Besides, massage was also effective for crying duration, blood oxygen saturation both during and after the procedure, but non-effective for the variation of respiratory rate after the procedure, and heart rate both during and after the procedure.

CONCLUSIONS

Massage may have a positive effect on pain relief of neonate, and rigorous trials are needed in the future to determine the most effective massage method.

Efficacy and safety of combined oral sucrose and nonnutritive sucking in pain management for infants: A systematic review and meta-analysis

Background

Pain management is currently important in neonatal intensive care unit (NICU). The superiority in pain relief of the combined oral sucrose (OS) and nonnutritive sucking (NNS) to other single intervention has not been well established. The administration of sucrose has been considered to potentially induce adverse events, which has been controversial. This study aims to investigate the combined effects and safety in comparison with other single intervention methods, including NNS, OS alone, breast milk and oral glucose.

Methods

We searched databases including Medline (via Pubmed), Embase (via Ovid), web of science, and Cochrane Library for randomized controlled trials from Jan 1, 2000 to Mar 31, 2021. The data were analyzed in the meta-analysis using Review manager Version 5.3. Pain score was the primary outcome in this meta-analysis. The adverse events were assessed qualitatively.

Results

A total of 16 studies were eligible in the meta-analysis. The results demonstrated a significant reduction in pain score in the NNS+OS group compared with NNS alone (SMD = -1.69, 95%CI, -1.69,-0.65) or sucrose alone (SMD = -1.39, 95% CI, -2.21,-0.57) during the painful procedures. When compared NNS+OS with breast milk, no significant difference was detected (SMD = -0.19, 95% CI: -0.5, 0.11).

Conclusion

The combined effects of NNS and OS might be superior to other single intervention method. However, the effects might be mild for moderate-to-severe pain.

Managing acute pain in children presenting to the emergency department without opioids

Pediatric pain is challenging to assess and manage. Frequently underestimated in children, untreated pain may have consequences including increased fear, anxiety, and psychological issues. With the current opioid crisis, emergency physicians must be knowledgeable in both pharmacologic and non‐pharmacologic approaches to address pain and anxiety in children that lead to enhanced patient cooperation and family satisfaction. This document focuses pain management and distress mitigation strategies for the brief diagnostic and therapeutic procedures commonly performed.

2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility

RATIONALE

A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available.

OBJECTIVE

To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility.

DESIGN

The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to.

METHODS

Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence.

RESULTS

The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements.

CONCLUSIONS

The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.

Effect of Non-nutritive Sucking during Heel-stick Procedure in Pain Management of Term Infants in the Neonatal Intensive Care Unit: A Systematic Review and Meta-analysis

BACKGROUND

This study aimed to evaluate the efficacy of non-nutritive sucking for analgesia in term infants undergoing heel-stick procedures.

METHODS

Randomized controlled trials and non-randomized studies based on the PICO framework were included in the study. Review articles, commentary, pilot, and non-English articles were excluded. Databases, such as PubMed/MEDLINE, Embase, Scopus, Web of Science, and Cochrane, were searched until January 31st, 2021, using the keywords "Pain management", 'Non-nutritive sucking", and "Heel stick". All studies were reviewed and retrieved by two authors independently using a standardized form according to the inclusion criteria, and any disagreements were examined by a third scholar. Quality assessment was evaluated by using the ROB-2 tool. Data were analyzed using Stata version 12.0 software, and a random-effects model was used for analysis.

RESULTS

A total of 5,629 articles were retrieved from all databases, and after the screening, finally, 6 relevant articles were included in the analysis. The tools used to control pain in infants in the articles included PIPP, NFCS, NIPS, and NPASS. The results showed that the pain scores were significantly lower in the NNS group compared to the control group (MD, -1.05; 95% CI, -1.53 to -0.57) and NNS had a significant effect on oxygen saturation (O2 Sat) increasing in newborns compared to the control group, but no significant reduction in the heart rate (HR) between two groups was observed.

CONCLUSION

NNS effectively provides analgesia in full-term neonates undergoing heel-stick procedures; however, its effects on the long-term outcomes of infants are unclear. The results showed that NNS was effective in improving heel-stick pain in infants.

Pain in Preterm Infants: Different Perspectives

In the last decades, there has been a tremendous change in approaching and managing neonates' pain. These changes began with rebutting the previous misconception about neonates' , particularly preterm infants' , pain. The development in neuroimaging has revealed that by 24 weeks of gestation the peripheral nervous system is mature and function fully. Researchers now know that neonates experience pain and premature infants have even lower pain thresholds. Since that time, a mounting amount of literature has addressed the issue of neonatal pain. Many pharmacological and non pharmacological pain reduction strategies have been investigated for their safety and analgesic effectiveness. Many interventions such as nonnutritive sucking (NNS), skin-to-skin contact (SSC), and facilitated tucking are effective in controlling neonates pain.

Sedoanalgesia in neonatal units

Pain recognition and management continues to be a challenge for health professionals in Neonatal Intensive Care Units. Many of the patients are routinely exposed to repeated painful experiences with demonstrated short- and long-term consequences. Preterm babies are a vulnerable high-risk population. Despite international recommendations, pain remains poorly assessed and managed in many Neonatal Intensive Care Units. Due to there being no general protocol, there is significant variability as regards the guidelines for the approach and treatment of pain between the different Neonatal Intensive Care Units. The objective of this article is to review and assess the general principles of pain in the initial stages of development, its recognition through the use of standardised scales. It also includes its prevention and management with the combination of pharmacological and non-pharmacological measures, as well as to establish recommendations that help alleviate pain in daily clinical practice by optimising pain and stress control in the Neonatal Intensive Care Units.

Effect of combined pharmacological, behavioral, and physical interventions for procedural pain on salivary cortisol and neurobehavioral development in preterm infants: a randomized controlled trial

Repeated procedural pain may lead to increased secretion of cortisol and future neurobehavioral development disorders in preterm infants. Changes in the cortisol level may mediate the effect of neonatal repetitive procedural pain on altered childhood neurobehavioral development in preterm infants. However, few studies have investigated the effect of combined pharmacological, behavioral, and physical interventions over repeated painful procedures on pain response, cortisol level, and neurobehavioral development. This study examined (1) the efficacy and safety of sucrose combined with massage, music, non-nutritive sucking, and gentle human touch to treat preterm infants with repeated procedural pain; (2) the cortisol level at discharge from the neonatal intensive care unit (NICU); (3) neurobehavioral development at 40 weeks' corrected gestational age; and (4) the potential mediating effect of the cortisol level in the combined interventions on neurobehavioral development. Stable preterm infants (n = 76) were randomized to receive routine care or combined interventions across repeated painful procedures throughout their NICU stay. The Premature Infant Pain Profile scores in the early, middle, and late periods of the NICU stay were measured, as were the basal salivary cortisol level at admission and discharge, the Neonatal Behavioral Neurological Assessment score at 40 weeks' corrected gestational age, and the incidence of adverse effects during the study period. Our findings indicated that the combined interventions remained efficacious and safe for reducing repeated procedural pain, decreased the cortisol level at discharge, and promoted early neurobehavioral development in preterm infants. This effect may have been mediated through decreased cortisol levels and reduced repeated procedural pain.

Comparing the Analgesic Effects of 4 Nonpharmacologic Interventions on Term Newborns Undergoing Heel Lance: A Randomized Controlled Trial

This randomized trial compared the analgesic effect of 4 nonpharmacologic interventions (breastfeeding, oral sucrose, nonnutritive sucking, and skin-to-skin contact) on term newborns between 24 and 48 hours of age who underwent a heel lance. The Neonatal Pain, Agitation, and Sedation Scale was used to evaluate pain. The newborns (N = 226) were assigned to one of 4 intervention groups (n = 176) or a control group without pain intervention (n = 50). The results indicate that all intervention groups showed decreased pain levels when compared with the control group (P < .01). The oral sucrose group experienced a superior analgesic effect when compared with the skin-to-skin contact group (P < .01), but no difference was observed when compared with the breastfeeding group (P > .05) or the nonnutritive sucking group (P > .05). All intervention groups showed a shortened crying time (P < .01) and reduced procedural duration (P < .01) compared with the control group. All of these interventions are clinically applicable and acceptable when caring for a newborn during a minor painful procedure.

Comparison of the analgesic effect of oral sucrose and/or music in preterm neonates: A double-blind randomized clinical trial

OBJECTIVE

To compare the analgesic effects of sucrose, music, and their combination on venipuncture's pain in preterm neonates.

METHODOLOGY

A double-blinded randomized control trial conducted at a Neonatal Intensive Care Unit (NICU) affiliated to Tehran University of Medical Sciences (TUMS) in Tehran, Iran. One hundred and twenty preterm neonates were randomly allocated into three experimental (sucrose, music and combination of sucrose and music) and one control groups (n = 30 for each group). Two minutes before the venipuncture, 0.5 ml of oral 24% sucrose was provided for the sucrose and combination groups. The combination group additionally received lullaby music as same as the music group. The control group had headphones without playing music and received sterile water. Blinded assessment of the Premature Infant Pain Profile (PIPP) was performed before and during venipuncture, as well as 30 s and 10 min and 10 min after its completion.

RESULTS

The pain scores during venipuncture in the sucrose and combination groups were significantly lower than the control group (p = .003, p < .001, respectively) but not in the music group. Thirty seconds after the end of the venipuncture, the pain score in the three intervention groups was significantly lower than the control group (sucrose, music and, combination group, p < .001, p = .009, p < .001, respectively). Ten min after the venipuncture, there was no significant difference in pain scores among the four groups.

CONCLUSION

Music could relief pain 30 s after the venipuncture completion but not during the venipuncture. A more prolonged period of playing music is recommended to evaluate the analgesic effects of music in preterm neonates in future studies.

Managing Procedural Pain in the Neonate Using an Opioid-sparing Approach

PURPOSE

Pain in the neonate is often challenging to assess but important to control. Physicians often must balance the need for optimal pain control with the need to minimize oversedation and prolonged opioid use. Both inadequate pain control and overuse of opioids can have long-term consequences, including poor developmental outcomes. The aim of this review is to introduce a comprehensive approach to pain management for physicians, nurses, and surgeons caring for critically ill neonates, focusing on nonopioid alternatives to manage procedural pain.

FINDINGS

After review, categories of opioid-sparing interventions identified included (1) nonopioid pharmacologic agents, (2) local and regional anesthesia, and (3) nonpharmacologic alternatives. Nonopioid pharmacologic agents identified for neonatal use included acetaminophen, NSAIDs, dexmedetomidine, and gabapentin. Local and regional anesthesia included neuraxial blockade (spinals and epidurals), subcutaneous injections, and topical anesthesia. Nonpharmacologic agents uniquely available in the neonatal setting included skin-to-skin care, facilitated tucking, sucrose, breastfeeding, and nonnutritive sucking.

IMPLICATIONS

The use of various pharmacologic and interventional treatments for neonatal pain management allows for the incorporation of opioid-sparing techniques in neonates who are already at risk for poor neurodevelopmental outcomes. A multifactorial approach to pain control is paramount to optimize periprocedural comfort and to minimize the negative sequelae of uncontrolled pain in the neonate.

Narcotics and sedatives use in the mechanical ventilation in preterm infants: Predictors and outcome

BACKGROUND

Mechanical ventilation (MV) causes discomfort but whether it causes pain remains controversial. Around the world neonatal intensive care units (NICU) often utilize narcotics and/or sedatives during MV of vulnerable infants yet the association with adverse neonatal outcomes has not been adequately addressed.

OBJECTIVE

Test for associations between the use of narcotics/sedatives during MV and mortality/morbidity in preterm infants in a large infant cohort in Canada.

DESIGN/METHODS

Preterm infants born <35 weeks gestational age (GA) requiring MV for >24 hrs were identified retrospectively from the Canadian Neonatal Network database, 2010-12. Infants were categorized according to whether they received narcotics/sedatives for greater than 24 hours concurrently with MV. Infants were excluded if moribund on admission, had major congenital anomalies, diagnoses where narcotic administration is routine and suspected seizures. Multivariable logistic and linear regression analysis tested for association of narcotics/sedatives use during MV with mortality/morbidity (nosocomial infections, BPD, ROP, IVH) and length of MV.

RESULTS

After exclusions the cohort included 2672 infants; 467(17%) exposed only to narcotics 101(4%) only to sedatives and 299(11%) to both. All models were adjusted for GA, gender, small for GA, SNAP-II score >20, multiple births, delivery mode, outborn, PDA status, MV type, use of high flow, muscle relaxant use, indwelling lines, caffeine and surfactant therapy. The composite mortality/morbidity, and MV days were significantly higher for MV infants exposed to narcotics, sedatives or both compared to infants not exposed.

CONCLUSION

Mounting evidence of the adverse short and long-term impacts of narcotics/sedatives during MV supports the need for further work in alternative therapies.

Randomised controlled trial showed that neonates received better pain relief from a higher dose of sucrose during venepuncture

AIM

We compared the effect of two different doses of sucrose on neonatal pain scores during venepuncture.

METHODS

This randomised crossover study focused on neonates born weighing more than 1000 g from December 2014 to June 2016, who received neonatal intensive care at two hospitals: one in Empangeni, South Africa, and one in Trondheim, Norway. During two consecutive venepuncture procedures, 27 neonates from South Africa and 26 neonates from Norway were randomised to receive 0.2 mL or 0.5 mL sucrose. Half was administered two minutes before venepuncture and the rest immediately before the procedure. South Africa used 25% sucrose and Norway 24%. Pain scores were measured twice using the Premature Infant Pain Profile-Revised: during skin puncture and after the needle was removed.

RESULTS

The mean pain scores during skin puncture were significantly lower with 0.5 mL sucrose than with 0.2 mL (5.3 versus 6.8, p=0.008), but the mean pain scores after the needle was removed were similar with both doses (4.7 versus 5.4, p=0.29). We found no significant association between weight and pain scores.

CONCLUSION

We showed that neonates received better pain relief from 0.5 mL than 0.2 mL sucrose during venepuncture but not after the needle was removed.