SUCROSE AS AN ANALGESICS IN NEWBORN INFANTS

Dr Amar M Taksande; Dr K Y Vilhekar; Dr Manish Jain; Dr Sherin Varkey; Dr Sheshu Rao

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Dr Amar M Taksande¹, Dr K Y Vilhekar¹, Dr Manish Jain¹, Dr Sherin Varkey², Dr Sheshu Rao¹.

¹Department of Pediatrics, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra,
²Department of Community Medicine, Mahatma Gandhi Institute Of Medical Sciences, Sevagram, Wardha, Maharashtra.

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Abstract

Objective: To assess the analgesic effect of orally administered sucrose in healthy full term newborn.

Design: Randomised controlled study

Setting: MGIMS Rural hospital, Level II Neonatal intensive care unit

Participants: 100 healthy neonates 7days, requiring bilirubin estimation, blood sugar etc. were randomized in experimental group (50 neonates) and control group (50 neonates). The experimental group was given 2ml of 25% sucrose solution 2minutes before the venepuncture.

Intervention: All parameters were recorded 3 minutes prior, during and 3 minutes after the procedure. Duration of crying over first three minutes after venepuncture was recorded.

Measurements: Evaluated NIPS score, crying time and respiratory rate. Heart rate and oxygen saturation observed on Datex-Ohmeda multimonitor.

Results: After the venepuncture, there was significant reduction in heart rate (p<0.001), respiratory rate (p<0.001), NIPS score (p<0.001), oxygen saturation (p<0.001) and crying time (p<0.001) after three minutes in the neonates given 2ml of 25% sucrose (weight/volume) as compared with the controls.

Conclusion: Sucrose solution seems to reduce crying and the physiological effect of a painful procedure in healthy neonates.

KEY MESSAGES :

1.	Giving 2ml of 25% sucrose solution before venepuncture in neonates can significantly reduce crying time.
2.	Sucrose is a useful and safe analgesic for minor procedure in neonates.

Introduction

The ability of neonates to perceive and react to pain has recently been acknowledged (1,2). Treating pain in the newborn is essential for ethical reasons and because pain can lead to decreased oxygenation, hemodynamic instability, or increased intracranial pressure (2). Recent research has shown that even short term pain can have lasting negative effects (3). Infants are unable to verbalize pain, caretakers must rely on behavioral, physiologic, or hormonal clues. Crying, the primary mode of infant communication, is the most commonly used measure for pain (4). Other measures used for measuring pain in infants include facial expressions, heart rate, blood pressure, oxygenation, and levels of stress hormones such as catecholamines and cortisol. Recently, composite pain scores using a multivariate approach have been shown to have validity in measuring pain in infant (5-8).

Blood samples for serum bilirubin and blood sugar estimations are taken when clinically indicated, and if a neonate is sick, frequent blood sampling, venepuncture and more severe procedures which cause tissue injury are common.Sucrose has been reported to have analgesic properties in newborns, both animal and human. The mechanism for the analgesic effect is thought to be via the release of endogenous opiates triggered by sweet taste, although the salience of a taste is immediately calming and distracting. Studies in which other saccharides were tested for analgesic properties provide support for the sweet taste hypothesis (9). Sucrose administered orally before painful procedures has shown a decrease in the following: Duration of crying, facial action associated with pain, heart rate, composite pain scores (10).

We assessed the use of sucrose to reduce pain in neonates subjected to routine blood sampling by venepuncture.

Methods & Materials

Informed consent was taken from the parent of the neonates. 100 healthy full term infants less than 7 days old, who required venepuncture for serum bilirubin estimations, blood sugar and septic workup were recruited from the postnatal wards. Babies with significant morbidity like septicemia, birth asphyxia, major congenital mal-formations, and neurological involvement were excluded. All blood samples were drawn by a single, experienced nurse using a sterile needle. Neonates were taken to a warm, quiet nursery for blood sampling and were fully unclothed. Before venepuncture, a Datex-Ohmeda multimonitor was applied to the baby's hand to measure changes in oxygen saturation and heart rate during the study. Babies were randomised to receive 2ml of 25% sucrose (wt./vol.) solutions on to the tongue. The test solution (2 ml) was given by syringe into the baby's mouth over less than one minute. Two minutes after the test solution venepuncture for blood sampling was done. The resident doctor rated neonates pain using NIPS at baseline (before the procedure), during (when maximal response was observed) and after the venepuncture. The resident doctor, was however blinded to the status of neonates with regards to receipt of sucrose. The NIPS includes five behavioral groupings (facial expression, crying, movement of arms and legs, and state of arousal) and one physiological indicator (breathing pattern). The total score ranges from 0 to 7 (11). Heart rate, respiratory rate and oxygen saturation were monitored continuously from 3 minutes before to 3 minutes after the procedure. Crying time was defined as the number of seconds that the baby cried within the first three minutes and the duration of the first cry was the duration of continuous crying before a quiet interval of five seconds (12).

The data was analyzed using EPI6 software for statistical analysis. The statistical tests for significance used included "Z" test for comparison of means and chi-square test for comparison of proportions.

Results

In the study group, there were total 100 neonates. There were no significant differences between the experimental and control groups in age, birth weight, gestational age, Male: Female ratio, Apgar at 5 min, time of last feed, and type of delivery. Detail of the babies are shown in Table 1.

Table 1. Characteristics of the study group

Characteristics	Experimental Group (n=50)	Control Group (n=50)
Age in days (mean + SD)	3.28 + 1.38	3.98 + 1.44 r2b3
Birth weight in kg (mean + SD)	2499.36 + 250.43	2469.32 + 378.98
Male : Female	29:21	27:23
APGAR at 5 minutes	9	9
Time of last feed in minutes (mean + SD)	59.6 + 36.89	50.22 + 23.97
Vaginal / LSCS delivery	32 / 18	36 / 14
Gestational age (wks) (mean)	38	38

The mean heart rate was increased after the venepuncture in both the groups, but the increase in heart rate in control group was significantly higher when compared to experimental group (p<0.001) (Table 2). The mean respiratory rate increased after the venepuncture in both the groups, but the increase in respiratory rate in control group was significantly higher when compared to experimental group (p<0.001) (Table 3). The mean oxygen saturation decreased after the venepuncture in both the groups, but the decrease in oxygen saturation in control group was significantly higher when compared to experimental group (p<0.001) (Table 4).

The mean NIPS score increased after the venepuncture in both the groups, but the increase in NIPS score in control group was significantly higher when compared to experimental group (p<0.001) (Table 5).

Table 2. Changes in Heart rate after the Venepuncture

	Heart Rate (beats/min)
Groups	Before (mean + SD)	After (mean + SD)	'p'
I. Experimental	134.72 + 9.41	140.7 + 9.56	<0.002
II. Control	131.62 + 11.48	149.58 + 13.58	<0.001

Table 3. Changes in Respiratory rate after the Venepuncture:

	Respiratory Rate (/min)
Groups	Before (mean + SD)	After (mean + SD)	'p'
I. Experimental	41.92 + 2.67	47 + 3.98	<0.001
II. Control	42.6 + 6.08	53.92 + 7.03	<0.001

Table 4. Changes in Oxygen saturation after the venepuncture:

	Oxygen saturation (%)
Groups	Before (mean + SD)	After (mean + SD)	'p'
I. Experimental	95.56 + 1.69	91.74 + 3.81	<0.001
II. Control	95.88 + 2.12	89.16 + 3.01	<0.001

Table 5: Changes in NIPS score after the venepuncture:

Groups	Before (mean + SD)	After (mean + SD)	'p'
I. Experimental	1.56 + 0.57	3.42 + 1.26	<0.001
II. Control	1.76 + 0.79	6.06 + 0.73	<0.001

The number of neonates crying at 1min, 2min, and 3min after venepuncture was significantly lower (p<0.001) in the experimental group in comparison with the control group (Table 6). There was also significant reduction in total crying time (p<0.001) in the experimental group as compared with the control group.

Table 6. Number of neonates crying after venepuncture

	Number of neonates crying after venepuncture (%)			P value
Groups	At 1 min	At 2 min	At 3 min	0.00002
I. Experimental	30 (60%)	10(20%)	0
II. Control	45 (90%)	30 (60%)	10(20%)

Discussion

Venipuncture is the recommended method for blood sampling in full-term neonates (13). Its advantages include an increased sample volume, greater efficacy, and less pain compared with heel stick (14-16). An optimal blood sampling technique might play some part in pain reduction, but an effective analgesic method that is easy to use during the venepuncture procedure also contributes to relieving the infant's distress (15-16).

Using a lancet to draw blood is a common procedure and is recognized to cause pain in patient able to report it (12). Now it is a well established fact that the anatomical, physiological and neurochemical structures which convey pain are well developed in neonates (17). Concentrated sucrose solution seems to reduce crying and the autonomic effects of a painful procedure in healthy normal babies. Sucrose may be a useful and safe analgesic for minor procedures in neonates (18). Lactose and human milk do not seem to have analgesic properties, but they are relatively less sweet than the other sugars studied (19,20). Sweet solutions may be an easy, useful, safe and cheap analgesic for minor invasive procedures in newborns (21).

The increase of heart rate indicates sympathetic nervous system activity. Heart rate increase has been reported during painful events (22,23). Ors R et al (24) and Haouari Net al (12) reported significant reduction in heart rate after three minutes in the babies given 50% sucrose as compared with controls. In our study, statistically significant reduction in heart rate and respiratory rate occurred within three minutes in the babies given 25% sucrose as compared with controls. Bilgen H et al (25) found that the infant body coding system (behavioral variables) in the sucrose group babies had significantly lower scores followed by the breast-fed and breast milk groups (P <0.001). Overgaard C et al (26) showed that sucrose significantly reduced the NIPS scores after the heel prick as was found in our study (p<0.001).

Crying is the primary method of communication in newborn infants and is also elicited by stimuli other than pain. The pain cry has specific behavioral characteristics and spectrographic properties in healthy full-term neonates (27). The motor responses of healthy full-term neonates to a pinprick in the leg were reported to be flexion and adduction of the upper and lower limbs associated with grimacing, crying, or both, and these responses were subsequently quantified (27).

Blass EM et al (28), Haouari Net al (11) and Harrison D et al (29) reported that infant who drank sucrose solution prior to blood collection cried 50% less during the blood collection procedure then did control infant. Our study suggested that after the intake of 2ml of 25% sucrose there was statistically significant reduction in crying time and the total duration of crying time as compare to controls(p<0.005).

We concluded that, giving neonates 2ml of 25% sucrose solution before venepuncture significantly reduces crying time and also affects the important physiological parameter. Hence sucrose can be used as a safe and effective analgesic in newborn infants.

Compliance with Ethical Standards

Funding None

Conflict of Interest None

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