This week, we are highlighting a series of three Cochrane summaries on interventions for procedural pain in infants.
We examined 13 different types of commonly investigated non-pharmacological treatments (excluding breastmilk, sucrose, and music) to determine their efficacy for pain reactions after an acutely painful procedure (right after the needle ('pain reactivity') and less immediate pain reactions ('immediate pain-related regulation'). Fifty-one randomized controlled trials were included involving 3396 participants. For preterm infants, there was sufficient evidence to recommend kangaroo care, sucking-related interventions, and swaddling/facilitated tucking interventions for both pain reactivity and immediate pain-related regulation. For neonates, there was sufficient evidence to recommend sucking-related interventions as an effective treatment for pain reactivity and immediate pain-related regulation. Rocking/holding was also found to be efficacious for neonatal immediate pain-related regulation. For older infants, there were no treatments reviewed that demonstrated sufficient evidence. Due to significant differences in the magnitude of treatment effects among studies (heterogeneity), some analyses that found a lack of treatment effect need to be interpreted with caution.
There is evidence that different non-pharmacological interventions can be used with preterms, neonates, and older infants to significantly manage pain behaviors associated with acutely painful procedures.
Breastfeeding provides pain relief for newborn babies undergoing painful procedures. Medicine for pain relief is commonly given for major painful procedures, but may not be given for minor painful procedures such as blood sampling (by heel prick or venepuncture). There are different forms of non-pharmacological strategies that may be used to reduce pain in babies, such as holding, swaddling them, sucking on a pacifier, or giving sweet solutions (such as sucrose or glucose). Different studies done in babies have shown that breastfeeding is a good way to reduce the pain babies feel when subjected to minor painful procedures. These studies have been done in full-term babies and they have shown that breastfeeding is effective by demonstrating that it reduces babies' crying time and reduces different pain scores that have been validated for babies. Breast milk given by syringe has not shown the same efficacy as breastfeeding itself. No studies have been done in premature babies, and so new studies are needed to determine if the use of supplemental breast milk in these small babies is effective in reducing their pain.
If available, breastfeeding or breast milk should be used to alleviate procedural pain in neonates undergoing a single painful procedure rather than placebo, positioning or no intervention. Administration of glucose/sucrose had similar effectiveness as breastfeeding for reducing pain. The effectiveness of breast milk for painful procedure should be studied in the preterm population, as there are currently a limited number of studies in the literature that have assessed it's effectiveness in this population.
Healthcare professionals need strategies to reduce newborn babies' pain. Sucrose (sugar) provides pain relief for newborn babies having painful events such as needles or heel pricks. Pain medicine is usually given for major painful events (such as surgery), but may not be given for more minor events (such as taking blood or needles). Pain medicine can be used to reduce pain but there are several other methods including sucking on a pacifier (dummy) with or without sucrose. Researchers have found that giving sucrose to babies decreases their crying time and behaviours such as grimacing. More research is needed to determine if giving repeated doses of sucrose is safe and effective, especially for very low birthweight infants or infants on respirators.
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.
Check out the full Cochrane systematic reviews below:
Pillai Riddell, R. R., Racine, N. M., Turcotte, K., Uman, L. S., Horton, R. E., Din Osmun, L., . . . Gerwitz-Stern, A. (2011). Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev(10), Cd006275. doi: 10.1002/14651858.CD006275.pub2
Shah, P. S., Herbozo, C., Aliwalas, L. L., & Shah, V. S. (2012). Breastfeeding or breast milk for procedural pain in neonates. Cochrane Database Syst Rev, 12, Cd004950. doi: 10.1002/14651858.CD004950.pub3
Stevens, B., Yamada, J., Lee, G. Y., & Ohlsson, A. (2013). Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev, 1, Cd001069. doi: 10.1002/14651858.CD001069.pub4
Related TREKK Resources:
This post is part of a weekly blog series highlighting pediatric emergency medicine (PEM) focused Cochrane summaries and other key resources selected by TREKK.
Published by arrangement with John Wiley & Sons.