Intra-oral administration of sweet-tasting substances and infants' crying response to immunization: a randomized, placebo-controlled trial

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.

Oral sucrose for analgesia in children aged between 3 months and 3 years undergoing transurethral bladder catheterisation: A randomised, double-blinded, clinical trial

AIM

Many children admitted to hospital undergo invasive, painful and stressful procedures, including children who are not toilet trained undergoing transurethral bladder catheterisation (TUBC). Oral sucrose is commonly given to children to reduce procedural pain. In this study, we evaluated the effectiveness of oral sucrose in reducing procedural pain in children aged between 3 months and 3 years undergoing TUBC.

METHODS

This study was a randomised, double-blind, placebo-controlled study conducted at Nepean Hospital, Sydney, Australia from June 2005 to June 2010. A total of 40 participants requiring TUBC for diagnostic evaluation were included. The participants were randomly assigned to receive 4 mL of 75% oral sucrose (n = 20) or a placebo (sterilised water) (n = 20). The primary outcomes were changes in two paediatric pain scale scores (the FLACC pain scale and the OUCHER pain scale), assessed by the parent/guardian(s), the doctor performing the TUBC and the nurse assisting. The secondary outcomes were physiological (changes in heart rate) and behavioural pain (crying) indicators.

RESULTS

Of the outcome measures, 65% favoured the oral sucrose group, 31% favoured the placebo group, and 4% found no difference between the oral sucrose and placebo groups.

CONCLUSION

While the trends favouring the sucrose group in this study were encouraging, as the results were not statistically significant, there was insufficient evidence to demonstrate the effectiveness of oral sucrose in reducing procedural pain in children aged between 3 months and 3 years undergoing TUBC.

To Regulate or Not to Regulate? The Future of Animal Ethics in Experimental Research with Insects

Regulatory ethical frameworks governing animal experimentation are a hallmark of modern biology. While most countries have ethical standards regarding the use of animals for scientific purposes, experiments involving insects are not included in these standards. With studies in recent years suggesting that insects may possess faculties akin to emotive states, there is growing discussion surrounding the ethical implications of scientific experimentation involving insects. This paper explores some of the current evidence for the ability of insects to experience emotive states and highlights how current formal animal experimentation ethics frameworks are unnecessary for governing the use of insects for scientific purposes. At its conclusion, this paper discusses ways in which scientists can, and should, uniformly maximise the welfare of insects used in their experiments in a way that is of benefit to their science as well as to the dignity and welfare of their study organisms.

Oral Sucrose Versus Breastfeeding in Managing Infants' Immunization-Related Pain: A Randomized Controlled Trial

BACKGROUND

Treating pain during immunization should be a part of pediatric primary healthcare around the world, as untreated pain in children has short- and long-term consequences. Few studies of pharmacologic and nonpharmacologic methods of pain relief during immunization have been conducted in low- and middle-income countries. Finding pain-mitigating interventions that are low-cost, effective, and feasible across all settings, including with low-resourced settings could improve primary healthcare.

PURPOSE

To evaluate the effectiveness of oral sucrose versus breastfeeding as methods of pain management during immunization of infants through 6 months of age.

METHODS

A randomized controlled experimental design was used; 120 infants were randomly assigned to control, sucrose, or breastfeeding groups. Data were collected in an Egyptian primary health center. Outcome measures including pain (as per the FLACC pain scale), crying time, and heart rate were measured at three time points.

RESULTS

There were significant differences in pain scores and crying duration during and after immunization (p < .001) for the breastfeeding group compared with the sucrose and control groups.

IMPLICATIONS FOR PRACTICE

Health staff and parents need education and support in use of breastfeeding for pain management during immunization. More studies are needed to evaluate effectiveness of breastfeeding versus other pain management methods for managing infants' immunization-related pain.

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.

A Randomized Controlled Trial Evaluating the Efficacy of Oral Sucrose in Infants 1 to 3 Months Old Needing Intravenous Cannulation

OBJECTIVES

The objective was to compare the efficacy of an oral sucrose versus placebo in reducing pain in infants 1 to 3 months of age during intravenous (IV) cannulation in the emergency department.

METHODS

A randomized, double-blind, placebo clinical trial was conducted. Participants were randomly allocated to receive 2 mL of an oral 88% sucrose solution or 2 mL of a placebo solution orally. The outcome measure were mean difference in pain score at 1 minute post-IV cannulation assessed by the Face, Legs, Activity, Cry, and Consolability Pain Scale (FLACC) and the Neonatal Infant Pain Scale (NIPS), crying time, and variations in heart rate.

RESULTS

Eighty-seven participants completed the study, 45 in the sucrose group and 42 in the placebo group. There was no statistical difference in variations in both the FLACC score (p = 0.49) and the NIPS score (p = 0.36) between the two groups as per the Mann-Whitney U-test. With the same test, median crying times following IV cannulation were statistically significantly different between both groups (17 seconds in the sucrose group vs. 41 seconds in the placebo group, p = 0.04). Mean changes in heart rate 1 minute after IV cannulation were similar in both groups (16 ± 4 beats/min for sucrose vs. 18 ± 4 beats/min for placebo, p = 0.74). Side effects were similar for both groups and no adverse events were reported.

CONCLUSIONS

Administration of an oral sucrose solution in infants 1 to 3 months of age during IV cannulation did not lead to statistically significant changes in pain scores. However, the cry time was significantly reduced.

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.

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.

Sweet tasting solutions for reduction of needle-related procedural pain in children aged one to 16 years

BACKGROUND

Extensive evidence exists showing analgesic effects of sweet solutions for newborns and infants. It is less certain if the same analgesic effects exist for children one year to 16 years of age. This is an updated version of the original Cochrane review published in Issue 10, 2011 (Harrison 2011) titled Sweet tasting solutions for reduction of needle-related procedural pain in children aged one to 16 years.

OBJECTIVES

To determine the efficacy of sweet tasting solutions or substances for reducing needle-related procedural pain in children beyond one year of age.

SEARCH METHODS

Searches were run to the end of June 2014. We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Cochrane Methodology Register, Health Technology Assessment, the NHS Economic Evaluation Database, MEDLINE, EMBASE, PsycINFO, and ACP Journal Club (all via OvidSP), and CINAH (via EBSCOhost). We applied no language restrictions.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCT) in which children aged one year to 16 years, received a sweet tasting solution or substance for needle-related procedural pain. Control conditions included water, non-sweet tasting substances, pacifier, distraction, positioning/containment, breastfeeding, or no treatment.

DATA COLLECTION AND ANALYSIS

Outcome measures included crying duration, composite pain scores, physiological or behavioral pain indicators, self-report of pain or parental or healthcare professional-report of the child's pain. We reported mean differences (MD), weighted mean difference (WMD), or standardized mean difference (SMD) with 95% confidence intervals (CI) using fixed-effect or random-effects models as appropriate for continuous outcome measures. We reported risk ratio (RR), risk difference (RD), and the number needed to treat to benefit (NNTB) for dichotomous outcomes. We used the I(2) statistic to assess between-study heterogeneity.

MAIN RESULTS

We included one unpublished and seven published studies (total of 808 participants); four more studies and 478 more participants than the 2011 review. Six trials included young children aged one to four years receiving sucrose or candy lollypops for immunisation pain compared with water or no treatment. Usual care included topical anaesthetics, upright parental holding, and distraction. All studies were well designed blinded RCTs, however, five of the six studies had a high risk of bias based on small sample sizes.Two studies included school-aged children receiving sweet or unsweetened chewing gum before, or before and during, immunisation and blood collection. Both studies, conducted by the same author, had a high risk of bias based on small sample sizes.Results for the toddlers/pre-school children were conflicting. Duration of cry, using a random-effects model, was not significantly reduced by sweet taste (six trials, 520 children, WMD -15 seconds, 95% CI -54 to 24, I(2) = 94%).Composite pain score at time of first needle was reported in four studies (n = 121 children). The scores were not significantly different between the sucrose and control group (SMD -0.26, 95% CI -1.27 to 0.75, I(2) = 86%).A Children's Hospital of Eastern Ontario Pain Scale score > 4 was significantly less common in the sucrose group compared to the control group in one study (n = 472, RR 0.55, 95% CI 0.45 to 0.67; RD -0.29, 95% CI -0.37 to -0.20; NNTB 3, 95% CI 3 to 5; tests for heterogeneity not applicable.For school-aged children, chewing sweet gum before needle-related painful procedures (two studies, n = 111 children) or during the procedures (two studies, n = 103 children) did not significantly reduce pain scores. A comparison of the Faces Pain Scale scores in children chewing sweet gum before the procedures compared with scores of children chewing unsweetened gum revealed a WMD of -0.15 (95% CI -0.61 to 0.30). Similar results were found when comparing the chewing of sweet gum with unsweetened gum during the procedure (WMD 0.23, 95% CI -0.28 to 0.74). The Colored Analogue Scale for children chewing sweet gum compared to unsweetened gum before the procedure was not significantly different (WMD 0.24 (-0.69 to 1.18)) nor was it different when children chewed the gum during the procedure (WMD 0.86 (95% CI -0.12 to 1.83)). There was no heterogeneity for any of these analyses in school-aged children (I(2) = 0%).

AUTHORS' CONCLUSIONS

Based on the eight studies included in this systematic review update, two of which were subgroups of small numbers of eligible toddlers from larger studies, and three of which were pilot RCTs with small numbers of participants, there is insufficient evidence of the analgesic effects of sweet tasting solutions or substances during acutely painful procedures in young children between one and four years of age. Further rigorously conducted, adequately powered RCTs are warranted in this population. Based on the two studies by the same author, there was no evidence of analgesic effects of sweet taste in school-aged children. As there are other effective evidence-based strategies available to use in this age group, further trials are not warranted.Despite the addition of four studies in this review, conclusions have not changed since the last version of the review.

Neonatal medications

Neonatal abstinence syndrome (NAS) is reaching epidemic proportions related to perinatal use of opioids. There are many approaches to assess and manage NAS, including one we have outlined. A standardized approach is likely to reduce length of stay and variability in practice. Circumcision is a frequent, painful procedure performed in the neonatal period. The rationale for providing analgesia is presented as well as a review of methods. Pharmacogenomics and pharmacogenetics have expanded our understanding of diseases and their drug therapy. Some applications of pharmacogenomics to the neonatal period are presented, along with pediatric challenges of developmental expression of drug-metabolizing enzymes.

Oral sucrose administration to reduce pain response during immunization in 16-19-month infants: a randomized, placebo-controlled trial

Although the analgesic effect of sucrose on newborns is well established, little is known about whether these solutions are effective in reducing procedural pain in infants beyond the newborn period. The purpose of this study was to determine the effect of sucrose solution given orally on infant crying times and measure the distress in a 16-19-month age group. A total of 537 healthy, 16-19-month-old infants attending for their immunizations with intramuscular diphtheria, tetanus, and acellular pertussis (DTaP)/Haemophilus influenza type b/IPV (along with oral polio vaccination (OPV)), intramuscular pneumococcus and intramuscular hepatitis A were randomized to receive 2 mL of a 75 % sucrose solution, a 25 % sucrose solution or sterile water 2 min before injections. Infants receiving a 75 % sucrose solution had significantly reduced total crying times and Children's Hospital of Eastern Ontario Pain Scale scores (CHEOPS) compared with infants in the control and 25 % sucrose solution groups (p < 0.001).

CONCLUSION

Sucrose solution reduces infant distress and is safe and clinically useful even for 16-19-month-old infants.

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.

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.

The effectiveness of glucose in reducing needle-related procedural pain in infants

This systematic review examined the effectiveness of glucose in relieving needle-associated pain in infants. Meta-analysis was not undertaken, and there was variation in dose, administration method, concentration, and outcome measurement. Glucose was more effective than placebo in relieving infant pain as measured by behavioral outcomes, but there were mixed findings for physiological outcomes. Based on these findings, 25%-50% glucose appears effective for infant pain management.

Sweet tasting solutions for reduction of needle-related procedural pain in children aged one to 16 years

BACKGROUND

Large numbers of studies have shown that oral sucrose or glucose, with or without non-nutritive sucking given prior to painful procedures result in a significant reduction in behavioral pain responses during or following painful procedures compared with placebo, no treatment or non-nutritive sucking alone, in newborns and infants up to 12 months of age. It is not known if these pain-reducing effects exist for older infants and children one year to 16 years of age.

OBJECTIVES

To determine the efficacy of sweet tasting solutions or substances for reducing needle-related procedural pain in children beyond one year of age.

SEARCH STRATEGY

We searched the following databases: the Cochrane Register of Controlled Trials (CCTR), MEDLINE, EMBASE, PsycINFO, ACP Journal Club, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Cochrane Methodology Register, Health Technology Assessment, and the NHS Economic Evaluation Database, and on the EBSCOhost interface: CINAHL. We applied no language or document type restrictions. We used the standard methods of The Cochrane Collaboration. The last date of the search was June 30, 2011.

SELECTION CRITERIA

Randomized controlled trials (RCTs) in which children from one year up to 16 years of age, received a sweet tasting solution or substance for needle-related procedural pain. Control conditions included water, non-sweet tasting substances, pacifier, distraction, no treatment, positioning/containment or breastfeeding.

DATA COLLECTION AND ANALYSIS

Outcome measures included composite pain scores, physiological or behavioral pain indicators, self-report of pain or parental- or healthcare professional-report of child's pain. We reported mean differences (MD) with 95% confidence intervals (CI) using fixed-effect or random-effects models as appropriate for continuous outcome measures. We planned to report risk ratio (RR) and risk difference (RD) for dichotomous outcomes. We used the Chi(2) test and I(2) statistic to assess between-study heterogeneity.

MAIN RESULTS

We included four studies (330 participants). Two studies focused on toddlers and pre-school children receiving sucrose for immunization pain compared with water or no treatment and two studies included school-aged children receiving sweet or unsweetened chewing gum before, or, before and during immunization and blood collection. Results for the toddlers/pre-school children were conflicting. Participants in the sucrose group in one study had significantly lower cry duration and behavioral pain scores, compared with the no intervention group, while crying time did not differ between the sucrose and the no intervention group in the other study. For school-aged children, chewing sweet gum either before, or during the procedure, did not significantly reduce pain scores.

AUTHORS' CONCLUSIONS

Based on these four studies, two of which were subgroups of small numbers of eligible toddlers from larger studies, there is insufficient evidence of the analgesic effects of sweet tasting solutions or substances during acute painful procedures in children over one year of age. Further well-conducted RCTs are warranted in this population.

The analgesic properties of intraoral sucrose: an integrative review

The treatment of pain is an essential component of the clinical and ethical care of infants. Despite evidence-based practice consensus statements recommending that infants receive analgesia during minor painful procedures, numerous studies have shown that procedural pain remains poorly managed in this population. Oral sucrose administration has been associated with calming effects and reductions in observed pain behaviors with preterm and term infants aged up to 1 year. The objective of this integrative review is to synthesize findings from published randomized controlled trials evaluating the efficacy and safety of oral sucrose as a preprocedural intervention for mild to moderate procedural pain in infants. Overall, studies indicate that oral sucrose is an effective, safe, convenient, and immediate-acting analgesic for reducing crying time and significantly decreases biobehavioral pain response following painful procedures with infants.

ABM clinical protocol #23: Non-pharmacologic management of procedure-related pain in the breastfeeding infant

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.

Analgesic effects of sweet-tasting solutions for infants: current state of equipoise

OBJECTIVE

The goal was to review published studies of analgesic effects of sweet solutions, to ascertain areas with sufficient evidence of effectiveness and areas of uncertainty.

METHODS

Databases searched included Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature database, and PsycINFO, using the terms pain*, infant*, neonat*, newborn*, sucrose, glucose, and alternative sugars. Publications were sorted according to type, year, painful procedure studied, placebo/no-treatment groups, population studied, and country of publication.

RESULTS

A total of 298 relevant unique publications involving human infants were identified; 125 (42%) were primary research studies, of which 116 (93%) were randomized controlled trials. Healthy preterm or term newborns were included in 82 studies (65%), and sick or very low birth weight infants were included in 22 (18%). Most studies included single episodes of painful procedures, with only 3 (2%) conducted over long periods. Procedures investigated most frequently were heel lance (49%), venipuncture (14%), and intramuscular injection (14%). Placebo or no-treatment groups were included in 111 studies (89%); in 103 (93%) of those studies, sweet solutions reduced behavioral responses, compared with placebo/ no treatment.

CONCLUSION

Clinical equipoise relating to analgesic effects of sweet solutions no longer exists for single episodes of procedures for healthy preterm and term newborn infants. Uncertainties include outcomes after prolonged use of sweet solutions, concomitant use of other analgesics, and effectiveness beyond the newborn period. Future research should focus on addressing these knowledge and research gaps.

NICU procedures are getting sweeter: development of a sucrose protocol for neonatal procedural pain

Neonates in the neonatal intensive care nursery experience multiple, painful, tissue-damaging procedures daily. Pain among neonates is often underestimated and untreated, producing untoward consequences. A literature review established strong evidence supporting the use of sucrose as an analgesic for minor procedural pain among neonates. A review of unit practices and nurses' experiential evidence initiated the production of a standardized protocol in our unit at the University of Washington Medical Center NICU in Seattle.Nursing practices surrounding sucrose use differed widely in dose, timing, and patient application. We carefully evaluated evidence documenting the effectiveness as well as the safety of sucrose administration and wrote a protocol and practice standards for our primarily premature patient population. This article describes the development and execution of a standardized, nurse-implemented, sucrose protocol to reduce procedural pain.

Sucrose for analgesia in newborn infants undergoing painful procedures

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Effectiveness of sucrose analgesia in newborns undergoing painful medical procedures

BACKGROUND

Sucrose is widely used to manage procedural pain in term newborns despite a lack of evidence of its effectiveness for different procedures and infant populations. Our objectives were to evaluate the effectiveness and safety of sucrose in newborns undergoing various medical procedures within 2 days of birth.

METHODS

We performed a double-blind, randomized controlled trial. We included newborns (>or= 36 weeks gestation) of diabetic mothers and nondiabetic mothers. Each newborn received 2 mL of a 24%-sucrose or placebo solution before all procedures. We used the Premature Infant Pain Profile to assess pain during intramuscular injection of vitamin K, venipuncture for the newborn screening test and the first 3 heel lances for glucose monitoring (newborns of diabetic mothers only). Scores ranged from from 0 (no pain) to 18 (maximum pain).

RESULTS

We included 240 newborns (120 from diabetic mothers, 120 from nondiabetic mothers). The overall mean pain score was lower among newborns who received sucrose than among those who received a placebo (mean difference -1.3, 95% confidence interval [CI] -2.0 to -0.6). We found that pain scores during intramuscular injection did not differ significantly between the sucrose and placebo groups for newborns of diabetic or nondiabetic mothers (newborns of nondiabetic mothers: mean difference -1.1, 95% CI -2.4 to 0.2; newborns of diabetic mothers: mean difference -1.0, 95% CI -2.4 to 0.4). During venipuncture, newborns who received sucrose had lower pain scores compared with those who received a placebo (newborns of nondiabetic mothers: mean difference -3.2, 95% CI -4.6 to -1.8; newborns of diabetic mothers: mean difference -2.4, 95% CI -3.8 to -1.0). Among newborns of diabetic mothers, there was no difference in pain during the first 3 heel lances or mean glucose levels between the sucrose and placebo groups (p = 0.94 and p = 0.29 respectively).

INTERPRETATION

We found a modest reduction of pain in newborns of both diabetic and nondiabetic mothers when sucrose was used for all medical procedures performed in the first 2 days after birth. However, when each procedure was analyzed separately, we found that the effectiveness of sucrose was limited to venipuncture for the newborn screening test. (http://Clinicaltrials.gov trial register no. NCT00213213.).

Stress at three-month immunization: parents' and infants' salivary cortisol response in relation to the use of pacifier and oral glucose

The aims of the present study were to investigate (1) whether the salivary cortisol response could be dampened during a routine three-month immunization if the infant received sweet-tasting solution in combination with a pacifier and (2) stress experienced by parents during immunization of the infant. Ninety-eight infants were included into one of four intervention groups: 'glucose and pacifier', 'water and pacifier', 'glucose', or 'water'. Saliva was collected before and 30 min after the immunization. Infants' crying-time and parents' self-reported stress (VAS) were measured before and after immunization. Infants in the 'pacifier and glucose' group had a significantly smaller change in salivary cortisol than infants in the other groups (F(3,72)=3.1, p<0.05). In the 'glucose and pacifier' group the median salivary cortisol levels decreased 33% after the immunization. In the 'water and pacifier', 'glucose', and 'water' group median cortisol increased with 50%, 42%, and 8%, respectively. No significant differences in crying-time were observed between the intervention groups. If the infant cried before the immunization, the crying-time during the immunization was longer (p<0.01) and cortisol increased more (p<0.05). Median cortisol levels for parents decreased after the immunization (p<0.01). Median VAS increased 50% (p<0.0001) after immunization. First time parents rated higher stress on VAS before immunization (p<0.01). Parents' change in cortisol and VAS were significantly related to infants' crying time. In conclusion, the combination of oral glucose and pacifier dampen infants' salivary cortisol in response to the three-month immunization.

Analgesic properties of oral sucrose during routine immunizations at 2 and 4 months of age

OBJECTIVE

The purpose of this work was to evaluate the analgesic properties of oral sucrose during routine immunizations in infants at 2 and 4 months of age.

PATIENTS AND METHODS

A prospective, randomized, placebo-controlled clinical trial was conducted at a pediatric ambulatory care clinic. One-hundred healthy term infants scheduled to receive routine immunizations were recruited, randomly stratified into 2- or 4-month study groups, and further randomly assigned to receive 24% oral sucrose and pacifier or the sterile water control solution. The study preparations were administered 2 minutes before the combined diphtheria-tetanus-acellular pertussis, inactivated polio vaccine, and hepatitis B vaccine. Haemophilus influenzae type b vaccine was administered 3 minutes after the combined injection, followed by the pneumococcal conjugate vaccine, 2 minutes after the H. influenzae type b injection. The University of Wisconsin Children's Hospital Pain Scale measured serial acute pain responses for the treatment and control groups at baseline and 2, 5, 7, and 9 minutes after solution administration. Repeated-measures analysis of variance examined between-group differences and within-subject variability of treatment effect on overall pain scores.

RESULTS

Two- and 4-month-old infants receiving oral sucrose (n = 38) displayed reductions in pain scores 2 minutes after solution administration compared with 2- and 4-month-old infants in the placebo group (n = 45). Between-group comparisons for the oral sucrose and placebo groups showed lower pain responses at 5, 7, and 9 minutes after solution administration. The oral sucrose and placebo groups demonstrated their highest mean pain score at 7 minutes, with a mean pain score of 3.8 and 4.8, respectively. At 9 minutes, the placebo group had a mean pain score of 2.91 whereas the mean pain score for the oral sucrose group returned to near baseline, reflecting a 78.5% difference in mean pain score (oral sucrose - placebo) relative to the placebo mean.

CONCLUSIONS

Oral sucrose is an effective, easy-to-administer, short-acting analgesic for use during routine immunizations.

Immediate effects of chocolate on experimentally induced mood states

In this work two hypotheses were tested: (1) that eating a piece of chocolate immediately affects negative, but not positive or neutral mood, and (2) that this effect is due to palatability. Experiment 1 (48 normal-weight and healthy women and men) examined the effects of eating a piece of chocolate and drinking water on negative, positive and neutral mood states induced by film clips. Eating chocolate reduced negative mood compared to drinking water, whereas no or only marginal effects were found on neutral and positive moods. Experiment 2 (113 normal-weight and healthy women and men) compared effects of eating palatable and unpalatable chocolate on negative mood, and examined the duration of chocolate-induced mood change. Negative mood was improved after eating palatable chocolate as compared to unpalatable chocolate or nothing. This effect was short lived, i.e., it disappeared after 3 min. In both experiments, chocolate-induced mood improvement was associated with emotional eating. The present studies demonstrate that eating a small amount of sweet food improves an experimentally induced negative mood state immediately and selectively and that this effect of chocolate is due to palatability. It is hypothesized that immediate mood effects of palatable food contribute to the habit of eating to cope with stress.

A randomized controlled trial of sucrose and/or pacifier as analgesia for infants receiving venipuncture in a pediatric emergency department

Background

Although sucrose has been accepted as an effective analgesic agent for procedural pain in neonates, previous studies are largely in the NICU population using the procedure of heel lance. This is the first report of the effect of sucrose, pacifier or the combination thereof for the procedural pain of venipuncture in infants in the pediatric emergency department population.

Methods

The study design was a double (sucrose) and single blind (pacifier), placebo-controlled randomized trial – factorial design carried out in a pediatric emergency department. The study population was infants, aged 0 – 6 months. Eighty-four patients were randomly assigned to one of four groups: a) sucrose b) sucrose & pacifier c) control d) control & pacifier. Each child received 2 ml of either 44% sucrose or sterile water, by mouth. The primary outcome measure: FLACC pain scale score change from baseline. Secondary outcome measures: crying time and heart rate change from baseline.

Results

Sucrose did not significantly reduce the FLACC score, crying time or heart rate. However sub-group analysis revealed that sucrose had a much greater effect in the younger groups. Pacifier use reduced FLACC score (not statistically significant), crying times (statistically significant) but not heart rate. Subgroup analysis revealed a mean crying time difference of 76.52 seconds (p < 0.0171) (0–1 month) and 123.9 seconds (p < 0.0029) (1–3 month). For subgroup age > 3 months pacifier did not have any significant effect on crying time. Age adjusted regression analysis revealed that both sucrose and pacifier had significant effects on crying time. Crying time increased with both increasing age and increasing gestational age.

Conclusion

Pacifiers are inexpensive, effective analgesics and are easy to use in the PED for venipuncture in infants aged 0–3 months. The benefits of sucrose alone as an analgesic require further investigation in the older infant, but sucrose does appear to provide additional benefit when used with a pacifier in this age group.

Trial registration

Current Controlled Trials ISRCTN15819627

Pain reduction during pediatric immunizations: evidence-based review and recommendations

The pain associated with immunizations is a source of anxiety and distress for the children receiving the immunizations, their parents, and the providers who must administer them. Preparation of the child before the procedure seems to reduce anxiety and subsequent pain. The limited available data suggest that intramuscular administration of immunizations should occur in the vastus lateralis (anterolateral thigh) for children <18 months of age and in the deltoid (upper arm) for those >36 months of age. Controversy exists in site selection for 18- to 36-month-old children. A number of studies suggest that the ventrogluteal area is the most appropriate for all age groups. Longer needles are usually associated with less pain and less local reaction. During the injection, parental demeanor clearly affects the child's pain behaviors. Excessive parental reassurance, criticism, or apology seems to increase distress, whereas humor and distraction tend to decrease distress. Distraction techniques vary with the age, temperament, and interests of the child, but their efficacy is well supported in the literature. Sucrose solution instilled directly into the mouth or administered on a pacifier reduces evidence of distress reliably in children <6 months of age and should be used routinely. Although there is no perfect topical anesthetic available at this time, selective use for children who are particularly fearful or who have had negative experiences in the past is highly endorsed. Pressure at the site, applied with either a device or a finger, clearly reduces pain. Finally, in the era of multiple injections, it seems that parents prefer that multiple injections be given simultaneously, rather than sequentially, if there are enough personnel available. Immunizations are stressful for many children; until new approaches are developed, systematic use of available techniques can significantly reduce the burden of distress associated with these procedures.

Oral glucose as an analgesic to reduce infant distress following immunization at the age of 3, 5 and 12 months

AIM

To evaluate oral glucose as an analgesic to reduce infant distress after immunization during the first year of life and to investigate if these effects change during this period.

METHODS

A prospective controlled trial of the effectiveness of glucose on crying response to immunizations at 3, 5 and 12 months of age. A total of 110 infants were randomized to receive 2 mL of 30% glucose or water. The same solution was given at 3, 5 and 12 months. Crying was registered from onset of the injection up to 120 seconds. Infanrix Polio Hib was administered intra-muscular in the thigh. Observation nurse and parents were blind to the nature of the solution.

RESULTS

Administration of glucose reduced the mean crying time by 22% at 3 months, 62% at 5 months and 52% at 12 months. The difference was significant at 5 and at 12 months. In the water group, there was a significant correlation between the children who cried at 3 months and who subsequently cried at 5 and 12 months. No correlations were found in the glucose group.

CONCLUSION

Sweet solution can be used as a simple and safe method to reduce the distress following immunization in infants up to 12 months.

Pain, position, and stylet styles: infant lumbar puncture practices of pediatric emergency attending physicians

OBJECTIVES

Lumbar punctures (LPs) are common emergency department (ED) procedures. Few pediatric studies exist to define training, guide practice, or indicate preferred methods for infants. While pain control is recommended, no recent studies indicate prevalence of analgesic use since the advent of topical anesthetics. We surveyed academic pediatric ED physicians to assess training and technique preferences and to highlight pain control usage.

METHODS

A total of 398 physicians were randomly selected from the 621 e-mail accessible members of the AAP Section on Pediatric Emergency Medicine. Questions concerning physician training, analgesia, and technique were either sent by regular mail or via e-mail link to a Web-based survey.

RESULTS

Of 359 deliverable surveys, there were 188 physician responses (52.4%) with differential response rates by survey format [58 e-mail (36%) and 130 regular mail responses (66%); P < 0.05]. Almost a third will advance the needle without the stylet in place. Two-thirds of physicians do not routinely use analgesia for neonatal LPs. Those using pain control were trained more recently (median 12 years vs. 15 years postresidency; P = 0.04). Analgesia use was the most common practice changed since residency.

CONCLUSIONS

Analgesia is underused for infant LPs. Advancing the needle without a stylet is not uncommon. Response rate to regular mail surveys was much higher.

EMLA cream and oral glucose for immunization pain in 3-month-old infants

The objective of this study is to determine whether use of lidocaine-prilocaine 5% cream (EMLA) and oral glucose decreases pain associated with diphteria-pertussis-tetanus (DPT) immunization in 3-month-old infants.

DESIGN

randomized, double-blind, controlled trial in outpatient paediatric practice in northern Sweden. EMLA or placebo was applied to the infant's lateral region of the right thigh and covered with an occlusive dressing 1h before the immunization. In addition, 1 ml of glucose (300 mg/ml) or placebo (water) was instilled on the baby's tongue within 2 min before the DPT-injection. Forty-five infants received EMLA and glucose and 45 infants placebo cream and water. ECG was recorded and stored in a computer and the procedure was videotaped. The parents and the nurse assessed the infants' pain on a visual analogue scale (VAS) after the immunization. Heart rate and heart rate variability pre- and post-injection were calculated. From the videotapes, the modified behavioural pain scale (MBPS) was used to assess pain scores during baseline and after immunization. The latency of the first cry and total crying time were measured. The parents and the nurse scored the infants' pain on the VAS significantly lower in the treatment group than in the placebo group. The infants' responses to the immunization measured as the difference in MBPS scores pre- and post-injection were significantly lower in the EMLA-glucose group compared with the placebo group. More infants cried after the immunization in the placebo group compared with the EMLA-glucose group and the latency of the first cry after the injection was shorter in the placebo group. A biphasic transient heart rate response with a marked deceleration followed by a subsequent acceleration was seen more frequently in the placebo group compared to the EMLA-glucose group. EMLA and glucose alleviate immunization pain in 3-month-old infants.