A Little Bit of Sucrose May Help the Hurt
ABSTRACT & COMMENTARY
Synopsis: Infant immunization by intramuscular injections is a distressing, painful procedure for both infants and parents. Oral administration of high concentration sucrose solutions shortly before injections significantly reduces the time of crying and the degree of distress as assessed by parents and nurses.
Source: Lewindon PJ, et al. Arch Dis Child 1998;78:453-456.
Recognizing that immunizations with intramuscular injections produce pain and distress in infants, Lewindon and associates in Adelaide, Australia, conducted a randomized, double-blind controlled trial of the effectiveness of oral sucrose solutions given shortly before intramuscular (i.m.) immunizations in reducing pain responses and crying. One hundred seven healthy infants receiving their 2-, 4-, or 6-month immunizations with oral polio vaccine, intramuscular diphtheria, tetanus and pertussis (DTP), and intramuscular Haemophilus influenzae type B (HIB) were randomized to receive either 2 mL of 75% sucrose solution or 2 mL of sterile water immediately before the two i.m. injections. Parents were encouraged to cuddle and soothe their infants after the immunizations. Parental acceptance and compliance were excellent.
The duration of crying of the infant during and immediately after the two i.m. injections was timed and recorded by a single nurse practitioner. The infants distress was independently assessed by a parent and the nurse practitioner using a visual analogue scale of pain (Oucher score). In the infants receiving sucrose, the mean duration of crying from start to finish was reduced by nearly 40%, from 69 to 43 seconds (P = < 0.002). The mean Oucher score as assessed by the nurse practitioner was reduced from 43 to 35 (P = < 0.02.) The parent's Oucher score showed a reduction that was not statistically significant.
Lewindon et al conclude that their study indicates that oral sucrose administration is well tolerated and effective in reducing the crying of infants after i.m. immunizations. This procedure should have great use in an immunization setting.
COMMENT BY STEVEN WEISMAN, MD
There is increasing concern in pediatric practice about subjecting infants and children to painful procedures without appropriate analgesia. Studies have demonstrated that pediatric patients have received less analgesia than adult patients undergoing comparable painful procedures. The most common painful procedure experienced by infants is immunization, a process involving multiple intramuscular injections during the first two years of life. Because immunizations are rapidly performed and are usually associated with only brief distress, analgesia has been given little attention. However, on occasion there may be consequences. Some parents are reluctant to subject their infants to another injection because of their perception of the distress associated with a previous injection, and this may lead to failure to complete immunization in infancy. Although not specifically advocated in the AAP Red Book, the National Health and Medical Research Council of Australia (as well as many pediatricians) suggest the use of acetaminophen or paracetamol before immunizations, primarily as an antipyretic, but it appears to have little analgesic effect.
A strength of this study was the fact that it was a blinded, randomized, placebo-controlled trial. Unfortunately, Lewindon et al's use of the Oucher Scale to assess their results was inappropriate. The Oucher Sale is self reported, not measured by a parent or nurse, and has been validated in children 3-8 years of age, not infants. There are pain scales for infants available such as the Newborn Infant Pain Scale (NIPS) or the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). Even the latter scale has been validated only down to 1 year of age. However, the most significant finding of the study was the reduction in crying time.
The taste of oral sucrose has been shown to stimulate endogenous cerebral opiod pathways in laboratory animals.1 Other studies have demonstrated that, with various concentrations of oral sucrose, crying time of infants undergoing heel stick blood collections is reduced.2 The effect of sucrose is rapid and seems to persist for 3-5 minutes.3 The combination of ease of administration, a high degree of parental acceptance, and an ideal time effect would seem to make sucrose premedication appropriate for infant immunizations. As more and more immunizations are added to the recommended menu of vaccines for American children, any simple and safe measure that may significantly reduce pain and distress should be considered. (Dr. Weisman is Associate Professor of Anesthesiology and Director of the Pediatric Pain Service at the Children's Hospital at Yale-New Haven, CT.)
References
1. Kanarek RB, et al. Pharmacol Biochem Behav 1991; 38:681-684.
2. Haouari N, et al. BMJ 1995;310:1498-1500.
3. Blass EM, et al. Pharmacol Biochem Behav 1987; 261:483-489.
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