Briefs: The sweet taste of pain relief

Are you about to perform a procedure on an infant? You know, like an IV, bladder cath or lumbar puncture. You probably won’t be giving IV sedative agents, but what can you do to make the infant more comfortable. This edition of Briefs is all about sucrose solution and its analgesic properties.

How do they work?

Sweet solutions in infants (regardless of whether or not it is sucrose or not) is thought induce an endogenous opioid response. Their use has been described as early as AD 632, “when Prophet Mohammed recommended giving infants a well-chewed date (Harrison, 2012).” The precise mechanism isn’t actually known, but as Harrison notes “sucrose was ineffective in calming methadone exposed infants suffering from withdrawal symptoms.” Hmmm, interesting – so it probably is the opioid receptors.

The length of time you get analgesic benefit varies, and it may not necessarily carry you through a 30 minute procedure. It is recommended that you give a pacifier dipped in sweet solution approximately 2 minutes before the start of the procedure. Then, repeat “doses” throughout. in practice I’ve re-dipped every 5 minutes or so. But titrate to the infant’s response to pain.

Sweet solutions have been studied in infants up to 12 months of age – I’ve used it more frequently in those under six months. I wouldn’t use one if the infant is NPO, even though the volume is small (FYI Sweet-Ease comes in 15mL cups).

What’s the evidence?

A recent meta analysis from Harrison et al. noted that almost 170 studies have assessed whether or not sweet solutions reduced pain in infants receiving a procedure. This is not the first meta analysis on the subject – but it does include more studies than the others. Many of these studies were placebo vs sweet and no-treatment vs sweet (methodology = good!). I think the authors did a good job of finding studies, incorporating the two previous systematic reviews and multiple search engines. They also assessed the individual studies’ risk of bias for new studies not included in the older systematic reviews. Below is the main forest plot, looking at mean crying time. Treatment is favored.

I recommend you take a look at the review – linked below as it will deepen your understanding of something you have probably used clinically already.

Sweet Solutions to Reduce Procedural Pain in Neonates: A Meta-analysis

And if you haven’t used sweet solutions what are you waiting for? Your own clinical experiences will help shape your practice (experiential learning to the max). Here are a few common scenarios:

  • An infant undergoing IV and/or bladder cath for workup of fever
  • A baby getting a heel stick for a bill level
  • As an adjunct to lidocaine in performing a lumbar puncture

References

Bueno M, Yamada J, Harrison D, et al. A systematic review and meta-analyses of nonsucrose sweet solutions for pain relief in neonates. Pain Res Manag. 2013;18(3):153–161.

Harrison et al. Sweet Solutions to Reduce Procedural Pain in Neonates: A Meta-analysis. PEDIATRICS Volume 139, number 1, January 2017.

Harrison et al. Sucrose for Procedural Pain Management in Infants. PEDIATRICS November 2012, Volume 130, Issue 5.

Stevens et al. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev. 2013;(1):CD001069.

Breath of the Wild! A podcast on breath holding spells

Don’t hold you breath while listening to this podcast – because you’d be doing so for longer than 20 seconds – and you will have apnea. Do however, listen to learn more about cyanotic and pallid breath holding spells so that you can be prepared to diagnose and manage them in the Emergency Department.

You can listen to the podcast right here:

 

…or check it out on iTunes or wherever you subscribe to your favorite podcasts.