Pain Management Hospitalized Infants Who Hurt: A...

In this article, we provide anoverview of oral sucrose analgesiafor infants. The administration oforal sucrose, with or without non-nutritive sucking (NNS), has beenthe most frequently studied non-pharmacological intervention forrelief of procedural pain in neonates.6

Oral sucrose has a beneficial role inpain prevention and managementfor infants, including babies in theemergency department.7,8 Althoughmost research on oral sucrose hasbeen conducted in newborn nurs-eries and neonatal intensive careunits (NICUs), we present 2 casereports that illustrate use of oralsucrose in pediatric and cardiacintensive care units and the variableresponses of the patients.

Deleterious Effects of Painfor Newborn InfantsPainful procedures place a new-

born at risk for brain damage.9-11

Moreover, brain damage and gener-ation of free radicals are associatedwith hypoxia.9 Rapidly developingtissues in a newborn, such as thelipid-rich brain, are particularlysusceptible to damage from free

Tracy Ann Pasek, RN, MSN, CCRN, CIMIJessica Marie Huber, RN, MSN, CCRN

Hospitalized Infants WhoHurt: A Sweet Solution WithOral Sucrose

Pain Management

indicates that early and repeatedexposure to pain leads to adverseneurological outcomes, yet babies inneonatal intensive care have a meanof 16 painful procedures a day, themajority of which are performedwith inadequate analgesia and com-fort measures.2-4

Infants, including preterm babies,for whom intravenous opioid anal-gesics are not indicated, usually aregiven no pain reliever or comfortmeasure for routine minor painfulprocedures.5 Examples of thesepatients include a neonate whosecritical condition is improving aftersurgery, a baby who is being evalu-ated for sepsis in the emergencydepartment, and an infant withnonaccidental trauma who is beingtransferred from the pediatric inten-sive care unit to an acute care unit.

Newborn infants whoare sick experiencemultiple invasive andtissue-damaging pro-cedures in emergency,

acute, and critical care units. Theseprocedures (eg, lancing the heel,suctioning an endotracheal tube)are presumed to be painful andoccur during the early days of lifeas part of stabilizing, diagnosing,and treating a baby’s condition.Although neonates are capable ofmounting powerful physiological,behavioral, hormonal, and meta-bolic responses to nociceptive stim-uli, these responses can be harmfulto an infant’s behavioral and neuro-logical development.1,2 Evidence

Pain is harmful to newborn infants. Oral sucrose is safe, inexpensive, and effec-tive at preventing and reducing pain in hospitalized babies who undergo invasiveprocedures. The sugar can be used alone or in combination with analgesics andother nonpharmacological interventions to provide analgesia. Parents expect nursesto serve as pain advocates for the parents’ newborns and to protect the babies fromneedless suffering. It is incumbent upon nurses to stay abreast of the current evidenceand integrate use of oral sucrose into daily pain management practice in emergency,acute, and critical care units. (Critical Care Nurse. 2012;32[1]:61-69)

©2012 American Association of Critical-Care Nurses doi: 10.4037/ccn2012912

www.ccnonline.org CriticalCareNurse Vol 32, No. 1, FEBRUARY 2012 61

by AACN on July 28, 2018http://ccn.aacnjournals.org/Downloaded from

http://ccn.aacnjournals.org

http://ccn.aacnjournals.org/

radicals.9-20 The destructive interplayof pain, hypoxia, and toxic effectscaused by free radicals leads to pooroutcomes. Table 1 lists conditionsof newborns that are associatedwith these effects.9-20 Nurses mustconsider the long-term deleteriouseffects of repeated unmanaged painfor patients in the NICU, includingpreterm babies.9 Table 2 lists severalroutine invasive and painful proce-dures infants must undergo duringhospitalization. Of these, the heellance is the most common painfulprocedure in NICUs.21

Standard of CareA report22 published in 2000

revealed that only 5% of neonatalunits routinely used analgesia forcommonly performed painful pro-cedures such as venipuncture and

insertion of central catheters. Eightyears later, Bellieni and Buonocore23

reported a 30% increase in painmanagement for similar procedures.This increase is an improvement,albeit an unsatisfactory one, in painmanagement. Full attention tobabies’ personhood, promotion of

infants’ well-being ratherthan solely sur-vival, andincreased moralurgency in pro-viding analgesiahave beendescribed asethical changesthat may resultin effective paincontrol forinfants andbabies.23,24

Oral sucroseis a valuableanalgesic optionfor neonatesundergoingbrief proceduralpain.25 It has arapid onset ofeffects andshort-livedaction, thoughtto be mediatedby the release ofendogenous

brain opioids. Use of the sugar is lowrisk and it is simple to administer.Moreover, this intervention requiresminimal time from busy nurses.

Description and Forms ofOral SucroseSucrose is a disaccharide com-

posed of a-glucose and fructose ina 1:1 ratio.26 It is obtained commer-cially from sugarcane, sugar beets(Beta vulgaris), and other plants.27

Commonly known as table sugar,sucrose is a fine, white, crystallizedodorless substance used extensivelyas a food and sweetener. Table 3 listsdescriptions of oral sucrose in theliterature. The terms are relatively

Tracy Ann Pasek is an advanced practice nurse in the pediatric intensive care unit at Children’sHospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Jessica Marie Huber is a staff nurse in the pediatric intensive care unit at Children’s Hospitalof Pittsburgh.

Authors

Corresponding author: Tracy Ann Pasek, RN, MSN, CCRN, CIMI, Advanced Practice Nurse, Pain/PICU, Children’sHospital of Pittsburgh of UPMC, One Children’s Hospital Dr, 4401 Penn Ave, Pittsburgh, PA 15224 (e-mail:[email protected]).

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected].

Table 1 Conditions of newbornsassociated with toxic effects of freeradicals

Increased arterial pressure

Increased intracranial pressure

Oxygen desaturation

Brain damage

Chronic lung disease

Retinopathy of prematurity

Necrotizing enterocolitis

Periventricular leukomalacia

Altered development

Abnormal sensitivity to pain

Table 2 Invasive and painful procedures experienced byhospitalized infantsa

Arterial puncture, peripheral arterial cutdown

Venipuncture, peripheral venous cutdown

Heel lance

Lumbar puncture

Umbilical catheter insertion

Peripherally inserted central catheter placement

Bladder catheterization

Suprapubic bladder tap

Adhesive tape removal

Suture removal

Ventricular tap

Central catheter insertion/removal

Chest tube insertion/removal

Nasogastric/orogastric tube placement

Feeding tube placement

Dressing changes

Percutaneous intravenous cannulation

Screening eye examination for retinopathy of prematurity

Intramuscular injections of vitamin K

Endotracheal tube suctioning

Immunizationsb

a Based on information from Anand et al.21b Although immunizations are normally associated with well babies and primarycare, the procedures are done in the hospital and therefore are included.

62 CriticalCareNurse Vol 32, No. 1, FEBRUARY 2012 www.ccnonline.org




synonymous for the same solutionand intent for use. The last 2 descrip-tions convey NNS more clearlybecause of the reference to a pacifier.When nurses evaluate the evidence,they should not discount studiesthat describe oral glucose as anintervention, because glucose is acomponent of sucrose. Oral sucrose is a solution of water

and sucrose. Two commercial oral

sucrose preparations are producedin the United States28,29 (Table 4).Ninety-one percent of the centersthat participated in a neonatalintensive care quality improvementcollaborative of 12 NICUs choseSweet-Ease (a prepackaged 11-mLcontainer).30 For the purpose of ourarticle, sucrose for infant analgesiais referred to as oral sucrose.

Research on Oral SucroseThe analgesic effects of sucrose

are not entirely understood. Themechanism of action is thought toinvolve activation of the endoge-nous opioid system (the release ofb-endorphins) through gustatorypathways or taste.31,32 A preabsorp-tive mechanism for sucrose-inducedanalgesia is supported by data on itspain-relieving effects after directapplication to the tongue but notafter administration into the

stomach via a nasogastric tube.31,33

Opioid receptors are present on thetongue, and studies in animals haverevealed analgesia reversal by opi-oid antagonists during noxiousstimulation.32 Conversely, findingsfrom 3 recent studies31,34,35 tend torefute the possibility of an endoge-nous opioid–mediated mechanismof effect of oral sucrose or a sweetsolution. Taddio et al31 found nosignificant difference in the serumconcentrations of b-endorphinsamong preterm infants before andafter a single dose of sucrose.Specifically, the authors31 found nodetectable increase in the serumlevels of the endorphins at the timethe analgesic effects of sucrose wereanticipated. Opioid tolerance wasnot observed in a study in whichinfants received repeated doses ofglucose.34 Finally, Gradin andSchollin35 found that intravenous

Table 3 Terms used for oralsucrose in published reports

Oral sucrose

Oral glucose

Lingual sucrose

Oral dextrose

Oral sucrose analgesia

Sugar solution analgesia

A sweet pacifier

A sucrose pacifier

Table 4 Commercial oral sucrose products

Products

Sweet-Easehttp://sweetease.respironics.com

TootSweethttp://www.natus.com

Product safety

Packaging

Hot filling by aFood and DrugAdministration–registered foodprocessingfacility

1-year shelf life

Stability at roomtemperature

Packaging

Fulfillment of anantimicrobialpreservativeeffectiveness test

Guarantee of amold- and bacteria-freesolution

2-year shelf life(cups and vials)

Preservative

Methylparabenand potassium sorbate

Preservative-free

Sweet-Ease Natural

No preservativesor artificialingredients

Packaging

Wide-based cupswith peel-back lid

Directions on foillid in English,Spanish, andFrench

Single patient use

Twist-tip vials

Wide-based cupswith peel-back lid

Single patient use

Manufacturer

Philips Children’sMedical Ventures,Monroeville,Pennsylvania

Natus MedicalIncorporated, San Carlos, California





injection of an opioid antagonistdid not diminish the analgesic effectsof orally administered glucose givenbefore blood-sample proceduresamong newborn infants. Table 5summarizes the infant pain assess-ment scales that have been used inthe research on oral sucrose.The appropriate group of patients

for sucrose analgesia continues tobe defined. Evidence36 supports theefficacy of sucrose, with or withoutNNS, as a nonpharmacological pain-relieving intervention for minor pro-cedural pain in healthy full-terminfants. Although NNS reduces painbehaviors and heart rate in responseto heel lance, the addition of oralsucrose may result in a superioranalgesic effect.36 Weaknesses in themethods used in some studies con-tribute to the obscurity of the distinctbenefits of oral sucrose in pretermor sick infants.36 Sucrose has anal-gesic effects in infants as young as25 weeks’ gestation, and most of themedical centers in a neonatal paincollaborative study used sucrose invery low-birth-weight infants.33,37-39

Despite the demonstration ofthe effectiveness of oral sucrose invery low-birth-weight infants, someresearchers38,39 suggest that limiting

the administra-tion of oralsucrose toinfants morethan 32 weeks’gestational agemay be judi-cious becauseof possibleadverse effects.Johnston40

described pos-sible long-termadverse effects

associated with the administrationof a 24% solution of oral sucrose toinfants less than 31 weeks’ postcon-ceptional age. Infants who receivedhigh numbers of doses scored lowerthan infants who received fewerdoses on components of the Neu-robehavioral Assessment of thePreterm Infant. In addition, babieswho received more doses of oralsucrose had higher NeurobiologicRisk Scores at 2 weeks’ postnatalage, but they did not have higherscores at discharge. During 54 glucose interventions

(0.3 mL of a 30% oral glucose solu-tion) that were administered toneonates during subcutaneous injec-tions, 7 of the babies experiencedslight (85%-88%) and transient oxy-gen desaturations.41 Five neonatesexperienced oxygen desaturationsduring the administration of glucoseonly, whereas 2 experienced oxygendesaturations during the administra-tion of glucose and a pacifier.41 Thesefindings contrast the absence of oxy-gen desaturations associated with24 administrations of placebo.41

Infants (27-31 weeks’ gestationalage) who received a 24% solution oforal sucrose alone experiencedchoking, coughing, vomiting, or

sustained tachycardia or bradycar-dia.42 None of these adverse eventswere considered clinically important,and none of the babies who receivedoral sucrose and NNS experiencedadverse events.42 McCullough et al25

described adverse events associatedwith administration of oral sucroseto preterm infants in stable condi-tion who had insertion of a nasogas-tric tube. Brief apnea or self-limitingbradycardia occurred in a few infantsas a result of the sucrose adminis-tered or insertion of the tube. Noneof these events were clinically impor-tant or required intervention.Necrotizing enterocolitis and hyper-glycemia have been suspected adverseeffects, the latter more theoreticalthan well documented.38 Oral sucrosehas not been proved to cause eitherof these effects.38

The safety of oral sucrose forvery preterm infants has been afocus of investigation, and the effi-cacy of the sugar in older infantshas been questioned. Scrutiny ofthe literature on pain associatedwith immunization and use of oralsucrose at 2, 4, and 6 months of agehas led experts to conclude that theanalgesic effect of oral sucrose isdiminished at 4 months.30,38,39,43

The appropriate volume of oralsucrose has also been examined,and precise dosing based on age isnot clearly defined. Two independ-ent measurements indicated that thevolume of a 24% solution of sucroseadministered from a pacifier dippedonce was no greater than 0.2 mL.38

Sucrose volumes ranging from 0.5to 2 mL have been effective for anal-gesia for neonates.30,38,39,43,44 Interest-ingly, the analgesic effect is notdetermined by the volume butrather by the infant’s detection of a

Table 5 Infant pain assessment instruments used inpublished research on oral sucrose analgesia

Cry, requirement for increased oxygen administration, increase invital signs, expression, and sleeplessness (CRIES) assessment

Neonatal Facial Coding System (NFCS)

Neonatal Infant Pain Scale (NIPS)

Neonatal Pain, Agitation, and Sedation Scale (N-PASS)

Premature Infant Pain Profile (PIPP)

Face, legs, activity, cry, consolability (FLACC) pain assessment scale

Douleur Aigue Nouveau-né (DAN) pain assessment scale

University of Wisconsin Children’s Hospital (UWCH) Pain Scale





sweet taste.38 Investigators38,44 havereported that 0.05 to 0.5 mL of a 24%to 25% solution of sucrose or glucoseis sufficient to provide analgesia.The onset of action of oral

sucrose is 10 seconds, peak actionoccurs at 2 minutes, and the effectpersists approximately 5 to 10 min-utes.37 Because of the rapid onset ofaction, analgesia is not attributableto oral absorption and clearancefrom the circulation. Research on use of oral sucrose

has evolved to include the investiga-tion of more and varied populationsof patients and painful procedures.For example, sucrose moderatelyreduced pain in newborns of bothdiabetic and nondiabetic motherswhen it was used for all medicalprocedures performed in the first 2days after birth.45 However, wheneach procedure was analyzed sepa-rately, sucrose reduced pain forvenipuncture but not for intramus-cular injection of vitamin K or heellance. Findings on the effectivenessof oral sucrose in reducing painand/or distress associated withscreening for retinopathy of prema-turity have been mixed.46,47

Studies other than those con-ducted in a NICU or a newborn nurs-ery have had varied findings on theuse of oral sucrose for non–skin-breaking procedures. For example,oral sucrose had no overall treatmenteffect in infants who were youngerthan 90 days and received the sugarfor bladder catheterization in theemergency department.48 Anotherexample is use of oral sucrose forinsertion of nasogastric tubes.McCullough et al25 reported thatinsertion in neonates evokes a painresponse comparable to that associ-ated with heel lance. In a randomized,

double-blind, placebo-controlledclinical trial,25 a 24% solution of oralsucrose was effective in reducingthe behavioral and physiologicalpain responses to insertion of anasogastric tube in preterm infants.Adverse effects (ie, brief apnea, self-limiting bradycardia) were few andoccurred equally in each group ofpatients, leading to the conclusionthat oral sucrose for this procedureis a safe intervention. Last, analgesia due to oral sucrose

administered for venipuncture maypersist through subsequent care suchas diaper changes.49 Table 6 lists vari-ations in research on oral sucroseanalgesia that make interpreting andimplementing the findings difficult.

Administration of Oral SucroseSummary proceedings from the

Neonatal Pain-Control Group21

include sucrose as a drug class andtherapeutic option for the preven-tion and management of neonatalpain and stress. In contrast, theAmerican Academy of Pediatricsand the Canadian Paediatric Soci-ety44 list oral sucrose as a nonphar-macological pain preventionmeasure for minor procedures.Many hospitals dispense oral sucrosethrough a supply chain or materials-management venue; others dispensethe product via the hospital phar-macy. Oral sucrose packaging doesnot include a national drug code.The logistics of an electronic med-ical record necessitate pharmacycontrol of oral sucrose if a providerorder and documentation on admin-istration as with a medication arerequired. Supplying oral sucrose onpatient care units as part of the units’stock instead of within the phar-macy or an electronic medication

Table 6 Variations in the evidence on analgesia with oral sucrose

Age (preterm, term, neonate, infant)

Weight (very low birth weight, low birth weight, healthy weight)

Acuity (healthy, undergoing mechanical ventilation with an endotracheal tube)

Intensity of pain stimulus (traditional lancet, automated lancet)

Oral sucrose as sole intervention

Oral sucrose as 1 of 2 or more interventions (breast milk, kangaroo care, facilitatedtucking by parents)

Clinical setting (newborn nursery, neonatal intensive care unit)

Pain assessment scale (N-PASS, PIPP, CRIES)

Pain assessment physiological parameters (oxygen saturation, heart rate, blood pressure)

Pain assessment timing (before, during, after procedure)

Pain assessment as sole metric or combined with distress measures

Sweet solution (glucose, sucrose, 10%, 24%, 50%)

Sweet solution preparation (commercial, prepared by pharmacy, natural, preserved)

Medical history (infant of healthy mother, infant of diabetic mother)

Ethics (placebo, standard of care)

Abbreviations: CRIES, cry, requirement for increased oxygen administration, increase in vital signs,expression, and sleeplessness assessment; N-PASS, Neonatal Pain, Agitation, and Sedation Scale; PIPP,Premature Infant Pain Profile.





dispensing system provides immedi-ate accessibility to clinicians and theretention of administration of oralsucrose as an independent nursingintervention guided by evidence-based pain policies and protocols.

Patient Safety and AdministrationAt one hospital, addition of oral

sucrose to preprinted admissionorders increased use of the sugarfrom 8% to 65% for obtaining bloodsamples at the time of admission.38

Oral sucrose may also be included inadmission order sets and pain man-agement screens or bands withinelectronic documentation systems.The data collection form of the

National Data Base for Nursing Qual-ity Indicators50 for pain assessment-intervention-reassessment cyclesdoes not include oral sucrose as aspecific analgesic intervention.However, the form does have thechoice for Other, and oral sucrosecan be included in this interventionoption. Nurses should have themeans to document oral sucrose asan intervention for pain managementwith reassessment of pain after theintervention. Nurses can documentoral sucrose as a component of apatient’s plan of care and pain edu-cation for an infant’s family. More-over, nurses may support parentsparticipating in this intervention.51

A patient care policy on use oforal sucrose should reflect consen-sus among the following disciplines:nursing, neonatology, general sur-gery, cardiothoracic surgery, painmedicine, critical care medicine, andpharmacy. A policy must specify whocan administer oral sucrose to new-borns when minor invasive proce-dures are performed (eg, radiological

technologists, phlebotomists). Insti-tution-specific factors (eg, productavailability) and parental prefer-ences are important considerationsin evidence-based practice. Table 7is an outline of the components of apolicy on use of oral sucrose. Dunbar and colleagues30 described

the administration of oral sucrosein combination with a pacifierbecause of the added analgesic effectof NNS. The oral sucrose wasdropped precisely onto the tonguewith an oral syringe and then theinfant was given a pacifier, or thesugar was administered by dippingthe pacifier in the sucrose solution.42

Figures 1 and 2 show oral sucrosepackaging and an administrationoption for different products.

Parental Participation inProcedures for Pain ManagementIn light of the number of inva-

sive procedures a hospitalized new-born experiences, not surprisinglyparents of babies in NICUs identi-fied medical procedures as the majorsource of pain.52 Parents desire infor-mation about and involvement withtheir infants’ pain and have described

Table 7 Oral sucrose policy components

1. Scope (eg, inpatient, outpatient laboratory, satellite surgery center)

2. Approval bodies/disciplines (eg, pain council, pharmacy)

3. Who can administer (eg, nurse, phlebotomist)

4. Purpose and definitions

5. Procedurea. When to administer relative to a painful procedureb. Method of administration (eg, pacifier, oral syringe)c. Information about pacifier dips and the volume of solutiond. Indications or inclusion criteriae. Contraindications or exclusion criteriaf. How families can participate with the administration of oral sucrose to their infantg. Documentation of pain assessment after administration of oral sucrose

6. Evidence

Figure 1 Packages of Sweet-Easenatural. Image courtesy of Philips Children’s MedicalVentures, Monroeville, Pennsylvania.

Figure 2 TootSweet twist-tip vial. Image courtesy of Natus Medical Inc, San Carlos,California.





specific ways in which staff in theNICU can help them and their babiescope with pain.53 Parents who areempowered to administer oral sucroseto their newborn might be lessaffected by the infant’s pain and lessworried about their relationshipwith the infant as a result of painfulexperiences. Nurses are in an idealposition to assess parents’ prefer-ences for being involved in manag-ing infants’ pain and to facilitateparental independence in providingnonpharmacological pain interven-tions as part of patient-family–centered care.

Case ReportsThe following case reports are

about 2 patients treated in unitsother than an NICU or a newbornnursery. The standard of care forminor painful procedures relative toanalgesic medications for infants isrepresented. Age determinants foranalgesic effectiveness are consid-ered as well as the combination oforal sucrose with other nonpharma-cological pain interventions. Incom-plete details on pain control beforethe time covered in these case reportschallenge nurses to consider possibleimplications for the effectiveness orineffectiveness of oral sucrose.

Case Report 1: Oral SucroseEffectiveA newborn boy with coarctation

of the aorta was hospitalized in acardiac intensive care unit. He wasswaddled in a radiant warmer bed.

His parents were consulting with aphysician outside the unit. No anal-gesics had been ordered as part ofthe baby’s treatment plan. Theinfant required percutaneous intra-venous cannulation before surgicalcorrection of the cardiac abnormal-ity. A pacifier dipped in a 24% solu-tion of oral sucrose was provided tothe infant by a nurse 2 minutesbefore the intravenous cannulation.The infant had mild extremity with-drawal in response to the firsttourniquet application; his CRIESscore was 1. The CRIES pain assess-ment scale is used to measure cry,requirement for increased oxygenadministration, increase in vital signs,expression, and sleeplessness.53,54

Scores can range from 0 (no pain) to10 (the worst possible pain). Whena site was chosen for the intravenouscannulation and the procedure wasstarted with a break in the skin, thebaby continued to suck on the oralsucrose pacifier. The pacifier wasredipped and offered to the baby 3times during the procedure and forapproximately 1 minute after thecatheter was secured. The baby sleptthrough most of the procedure. Dur-ing brief wakefulness, his CRIESscore never increased to greater than1. The baby was swaddled again,and he was resting peacefully whenthe parents returned to the bedside.

Case Report 2: Oral Sucrose Ineffective A 4-month-old girl was hospital-

ized in a pediatric intensive care unitwith severe bronchopulmonarydysplasia that necessitated high-frequency oscillatory ventilationand prone positioning. When thebaby’s condition improved, oxygenwas administered via nasal cannula.

She required percutaneous intra-venous cannulation for maintenanceintravenous fluid before transfer toan acute care unit the next morn-ing. The nurse caring for the babyplayed a television channel in theinfant’s room that shows continualimagery scenes accompanied bymusic (eg, waterfalls, green mead-ows). No analgesics were orderedas part of the baby’s treatmentplan. She was soothed only brieflywith oral sucrose for the first tourni-quet application to an extremity.As the procedure went on, with 3unsuccessful attempts at percuta-neous intravenous cannulation, oralsucrose had no effect on the infant’spain, as indicated by no reductionin a CRIES score of 8. Whether ornot adequate pain managementwas provided earlier during hospi-talization for multiple urgent andnecessary invasive procedures,potentially resulting in hyperalge-sia, was not clear. The ineffective-ness of oral sucrose might have beenattributable to the infant’s age.

ConclusionOral sucrose has a valuable role

in reducing procedural pain forinfants. Generally, the sugar is safeand effective for infants who experi-ence minor invasive procedures.Inconsistencies in studies of theanalgesic effects of oral sucrose dur-ing common minor invasive proce-dures may be responsible for thevaried findings. Furthermore, anoptimal dose has yet to be deter-mined. Nurses need to rememberthat oral sucrose reduces, but maynot eliminate, pain. Combining oralsucrose with other nonpharmaco-logical interventions may enhancepain relief. Oral sucrose should not

To learn more about neonatal critical care,read “Assessment of Family Needs in Neona-tal Intensive Care Units” by Cynthia A. Mundyin the American Journal of Critical Care, 2010;19:156-163. Available at www.ajcconline.org.





be used as a first-line interventionfor moderate, severe, or chronicpain in infants. Oral sucrose for analgesia in

newborns remains an area of researchand a relevant topic of interest.Additional investigation is neededon repeated administration of oralsucrose, optimal dosing, and use inbabies who have extremely lowbirth weight, are in unstable condi-tion, or are being treated withmechanical ventilation.55 CCN

AcknowledgmentIn loving memory of Beverly Sahlaney.

Financial DisclosuresNone reported.

References1. Anand KJS, Scalzo FM. Can adverse neonatal

experience alter brain development andsubsequent behavior? Biol Neonate. 2000;77(2):69-82.

2. Lago P, Garetti E, Merazzi D, et al; Pain StudyGroup of the Italian Society of Neonatology.Guidelines for procedural pain in the new-born. Acta Paediatr. 2009;98(6):932-939.

3. Lago P, Guadagni AM, Merazzi D, AncoraG, Bellieni CV, Cavazza A. Pain manage-ment in the neonatal intensive care unit: anational survey in Italy. Paediatr Anaesth.2005;15(11):925-931.

4. Carbajal R, Rousset A, Danan C, et al. Epi-demiology and treatment of painful proce-dures in neonates in intensive care units.JAMA. 2008;300:60-70.

5. Elserafy F, Alsaedi SA, Lourwrens J, Sadiq B,Mersale Y. Oral sucrose and a pacifier forpain relief during simple procedures inpreterm infants: a randomized controlledtrial. Ann Saudi Med. 2009;29:184-189.

6. Stevens B, Yamanda J, Ohlsson A. Sucrosefor analgesia in newborn infants undergo-ing painful procedures. Cochrane DatabaseSyst Rev. 2007;(4):CD001069. doi:10.1002/14651858.CD001069.pub2.

7. Gaspardo CM, Miyase CI, Chimello JT, Mar-tinez FE, Martins Linhares MB. Is pain reliefequally efficacious and free of side effectswith repeated doses of oral sucrose inpreterm neonates? Pain. 2008;137(1):16-25.

8. Harrison DM. Oral sucrose for pain man-agement in the paediatric emergencydepartment: a review. Australas Emerg NursJ. 2008;11(2):72-79.

9. Bellieni CV, Iantorno L, Perrone S, et al. Evenroutine painful procedures can be harmfulfor the newborn. Pain. 2009;147:128-131.

10. Bhutta AT, Anand KJ. Vulnerability of thedeveloping brain: neuronal mechanisms.Clin Perinatol. 2002;29:357-372.

11. Anand KJ, Garg S, Rovnaghi CR, Narsing-hani U, Bhutta AT, Hall RW. Ketaminereduces the cell death following inflamma-tory pain in newborn rat brain. Pediatr Res.2007;62:283-290.

12. Dorrepaal CA, Berger HM, Benders MJN,van Zoeren-Grobben D, Ban de Bor M, VanBel F. Nonprotein-bound iron in postas-phyxial reperfusion injury of the newborn.Pediatrics. 1996;98(5):883-889.

13. Buonocore G, Zani S, Perrone S, Caciotti B,Bracci B. Intraerythrocyte nonprotein-bound iron and plasma malondialdehyde inthe hypoxic newborn. Free Radic Biol Med.1998;25(7):766-770.

14. Mishra OP, Delivoria-Papdopoulos M. Cel-lular mechanisms of hypoxic injury in thedeveloping brain. Brain Res Bull. 1999;48:233-238.

15. Buonocore G, Perrone S, Longini M,Terzuoli L, Bracci R. Total hydroperoxideand advanced oxidation protein products inpreterm hypoxic babies. Pediatr Res. 2000;47:221-224.

16. Kakita H, Hussein MH, Dauoud GA, et al.Total hydroperoxide and biological antioxi-dant potentials in a neonatal sepsis model.Pediatr Res. 2006;60:675-679.

17. Kaindl AM, Sifringer M, Koppelstaetter A,et al. Erythropoietin protects the developingbrain from hyperoxia-induced cell deathand proteome changes. Ann Neurol. 2008;64:523-534.

18. Hall RW, Anand KJS. Short- and long-termimpact of neonatal pain and stress: morethan an ouchie. Neoreviews. 2005;6(2):e69.

19. Grunau RE, Holsti L, Peters JWB. Long-termconsequences of pain in human neonates.Semin Fetal Neonatal Med. 2006;11(4):268-275.

20. Pineles BL, Sandman CA, Waffarn F, Uy C,Davis EP. Sensitization of cardiac responsesto pain in preterm infants. Neonatology.2007;91(3):190-195.

21. Anand KJS, Aranda JV, Berde CB, et al.Summary proceedings from the NeonatalPain-Control Group. Pediatrics. 2006;117:S9-S22.

22. Sabrine N, Sinha S. Pain in neonates. Lancet.2000;355:932-933.

23. Bellieni CV, Buonocore G. Neonatal paintreatment: ethical to be effective. J Perinatol.2008;28:87-88.

24. Schecter N. Evolution of pediatric paintreatment In: Schmidt RF, Willis WD, eds.Encyclopedia of Pain.New York, NY: Springer;2007:749-752.

25. McCullough S, Halton T, Mowbray D, Mac-farlane P. Lingual sucrose reduces the painresponse to nasogastric tube insertion: arandomized clinical trial. Arch Dis ChildFetal Neonatal Ed. 2008;93(2):F100-F103.

26. Sucrose. 3Dchem.com Web site. http://www.3dchem.com/molecules.asp?ID=59. Pub-lished December 1996. Accessed November26, 2011.

27. Drug Information Portal. Search forSucrose. National Library of Medicine Website. http://druginfo.nlm.nih.gov/drugpor-tal. Accessed November 26, 2011.

28. Sweet-Ease Natural/Sweet-Ease Preserved.http://sweetease.respironics.com. AccessedNovember 26, 2011.

29. TootSweet. Natus Medical Inc, Hawaii Med-ical Web site. http://www.natus.com/index

.cfm?page=products_1&crid=462. AccessedNovember 26, 2011.

30. Dunbar AE, Sharek PJ, Mickas NA, et al.Implementation and case-study results ofpotentially better practices to improve painmanagement of neonates. Pediatrics.2006;118(suppl 2);S87-S94.

31. Taddio A, Shah V, Shah P, Katz J. b-Endor-phin concentration after administration ofsucrose in preterm infants. Arch PediatrAdolesc Med. 2003;157:1071-1074.

32. Kumar P. Prevention of pain in neonates.JAMA. 2008;300(19):2248-2249.

33. Ramenghi LA, Evans DJ, Leven MI. Sucroseanalgesia: absorptive mechanism or tasteperception? Arch Dis Child Fetal NeonatalEd. 1999;80:F146-F147.

34. Eriksson M, Finnstrom O. Can daily repeateddoses of orally administered glucose inducetolerance when given for neonatal pain?Acta Paediatr. 2004;93:2246-2249.

35. Gradin M, Schollin J. The role of endoge-nous opioids in mediating pain reductionby orally administered glucose among new-borns. Pediatrics. 2005;115:1004-1007.

36. Tsao JCI, Evans S, Meldrum M, Altman T,Zeltzer LK. A review of CAM for proceduralpain in infancy, II: sucrose and nonnutritivesucking. Evid Based Complement AlternatMed. 2008;5(4):317-381.

37. Blass EM, Shah A. Pain reducing propertiesof sucrose in human newborns. Chem Senses.1995;20(1):29-35.

38. Lefrak L, Burch K, Caravantes R, et al. Sucroseanalgesia: identifying better practices. Pedi-atrics. 2006;118(suppl 2):S197-S202.

39. Curtis SJ, Jou H, Ali S, Vandermeer B,Klassen T. A randomized control trial ofsucrose and/or pacifier for infants receivingvenipuncture in the emergency department.BMC Pediatr. 2007;7:27.

40. Johnston CC. The efficacy of sucrose analge-sia for procedural pain in preterm infants<32 weeks in the first week of life [abstract].Pediatr Res. 2000;47:405A.

41. Carbajal R, Lenclen R, Gajdos V, Jugie M,Paupe A. Crossover trial of analgesic efficacyof glucose and pacifier in very pretermneonates during subcutaneous injections.Pediatrics. 2002;110(2, pt 1):389-393.

42. Gibbins S, Stevens B, Hodnett E, Pinelli J,Ohlsson A, Darlinton G. Efficacy and safetyof sucrose for procedural pain relief inpreterm and term neonates. Nurs Res.2002;51:375-382.

43. Barr RG, Young SN, Wright JH, et al. “Sucroseanalgesia” and diphtheria-tetanus-pertussisimmunizations at 2 and 4 months. J DevBehav Pediatr. 1995;16(4):220-225.

44. American Academy of Pediatrics Commit-tee on Fetus and Newborn; American Acad-emy of Pediatrics Section on Surgery;Canadian Paediatric Society Fetus and New-born Committee, Batton DG, BarringtonKJ, Wallman C. Prevention and manage-ment of pain in the neonate: an update[published correction appears in Pediatrics.2007;119(2):425]. Pediatrics.2006;118(5):2231-2241.

45. Taddio A, Shah V, Hancock R, et al. Effec-tiveness of sucrose analgesia in newbornsundergoing painful medical procedures.CMAJ. 2008;179(1): 37-43.

46. Grabska J, Walden P, Lerer T, et al. Can oralsucrose reduce the pain and distress associ-ated with screening for retinopathy of pre-maturity? J Perinatol. 2005;25(1):33-35.

Now that you’ve read the article, create or contributeto an online discussion about this topic using eLetters.Just visit www.ccnonline.org and click “Submit aresponse” in either the full-text or PDF view of thearticle.





47. Boyle EM, Free Y, Khan-Orakzai A, et al.Sucrose and non-nutritive sucking for therelief of pain in screening for retinopathy ofprematurity: a randomised controlled trial.Arch Dis Child Fetal Neonatal Ed. 2006;91(3):166-168.

48. Rogers AG, Greenwald MH, Deguzman MA,Kelley ME, Simon HK. A randomized con-trolled trial of sucrose analgesia in infantsyounger than 90 days of age who requirebladder catheterization in the emergencydepartment. Acad Emerg Med. 2006;13(6):617-622.

49. Taddio A, Shah V, Katz J. Reduced infantresponse to a routine care procedure aftersucrose analgesia. Pediatrics. 2009;123(3):e425-e429.

50. Data collection form: Pain Assessment-Inter-vention-Reassessment Cycles. NationalDatabase of Nursing Quality Indicators Website. https://www.nursingquality.org.Accessed November 26, 2011.

51. Pasek TA, Lefcakis LA, O’Malley CK, LicataJ, Jackson P. Power in documentation: aneProgress note for APNs. Crit Care Nurse.2009;29(3):104, 102-103.

52. Franck L, Allen A, Cox S, Winter I. Parents’views about infant pain in neonatal inten-sive care. Clin J Pain. 2005;21(2):133-139.

53. Krechel SW, Bildner J. CRIES: a new neona-tal postoperative pain measurement score.Initial testing and reliability. PaediatrAnaesth. 1995;5(1):53-61.

54. Breivik H, Borchgrevink PC, Allen SM, et al.Assessment of pain. Br J Anaesth. 2008;101(1):17-24.

55. Stevens B, Yamada J, Ohlsson A. Sucrose foranalgesia in newborn infants undergoingpainful procedures. Cochrane Database SystRev. 2010;(1):CD001069. doi:10.1002/14651858.CD001069.pub3.





Tracy Ann Pasek and Jessica Marie HuberHospitalized Infants Who Hurt: A Sweet Solution With Oral Sucrose

http://ccn.aacnjournals.org/Published online ©2012 American Association of Critical-Care Nurses

10.4037/ccn2012912 61-69 32 2012;Crit Care Nurse

http://ccn.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECTPersonal use only. For copyright permission information:

http://ccn.aacnjournals.org/subscriptions/Subscription Information

http://ccn.aacnjournals.org/misc/ifora.xhtmlInformation for authors

http://www.editorialmanager.com/ccn Submit a manuscript

http://ccn.aacnjournals.org/subscriptions/etoc.xhtmlEmail alerts

362-2049. Copyright ©2016 by AACN. All rights reserved. bimonthly by AACN, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) Critical Care Nurse is an official peer-reviewed journal of the American Association of Critical-Care Nurses (AACN) published


http://ccn.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT

http://ccn.aacnjournals.org/subscriptions/

http://ccn.aacnjournals.org/misc/ifora.xhtml

http://www.editorialmanager.com/ccn

http://ccn.aacnjournals.org/subscriptions/etoc.xhtml


Pain Management Hospitalized Infants Who Hurt: A...

Documents

Transcript of Pain Management Hospitalized Infants Who Hurt: A...