Mariana Bueno, an Assistant Professor at the Lawrence Bloomberg Faculty of Nursing, is the lead author of a recently published Cochrane review investigating the administration of sucrose as a form of pain management for hospitalized infants who undergo venepuncture.
The review which included studies worldwide, found that sucrose administration stood out as an effective and safe option to manage pain and provide comfort to babies during venepuncture, especially when compared to no treatment.
"Giving infants a pacifier in addition to sucrose, can make the analgesic or pain-relieving effects of sucrose even better", says Bueno.
Other forms of pain management intervention for infants can include skin to skin, breastfeeding, or topical anaesthetics. Bueno notes that further research will be needed to compare the effectiveness of these interventions to sucrose administration, but the findings from this study indicate that, when possible, a pain intervention should be used before venepuncture.
"These findings also support what is already a recommendation in many infant care guidelines when it comes to sucrose administration," says Bueno, who is also a Pain Scientist at the University of Toronto Centre for the Study of Pain (UTCSP). "The challenge remains that more clinicians need to find a way to routinely implement pain management strategies for procedures."
Venepuncture, the procedure focused on in this review, is one that hospitalized infants are frequently submitted to, either for blood tests or to give fluids and medication through IV insertion. When performed by a skilled clinician, venepuncture can be less painful than heel lancing – the other method used for blood draws in infants – but it is often unsuccessful on the first attempt.
"We know that procedural pain for infants is poorly managed in low, middle and high-income countries, and that repeated exposure to untreated acute pain at early stages in life may lead to short and long-term changes to the structure and connectivity of the somatosensory system – essentially how the brain processes and perceives external stimuli," says Bueno.
It is also widely understood that repetitive and untreated pain in the early stages of life has a negative impact on growth and development. Infants hospitalized for extended periods of time are at an even greater risk of experiencing these negative side effects because they may be more repeatedly exposed to acute pain for procedures.
Sucrose is considered a medication, and Bueno adds that long-term effects of repetitive sucrose use, still need to be further evaluated. Clinicians she says, would need to be judicious in prescribing it, to avoid it being used unnecessarily to manage stress or crying in infants. Yet still, it is not used often enough in clinical practice settings.
"Sucrose is easy to administer on the baby's tongue two minutes before the procedure," says Bueno. "But there is a gap in the work being done to engage clinicians in changing their practice and using this evidence more intentionally when caring for hospitalized infants."
To address some of these barriers, Bueno notes that clinicians might follow a priority list for pain management strategies for infants.
"A first choice would be to offer skin to skin, then breastfeeding, and if those options are not available then sucrose should be administered. The message from our findings is ultimately that infants need and should receive pain management before a procedure such as venepuncture," says Bueno.
Bueno adds that NICU's are also complex and fast-paced environments and clinicians may not provide pain management for infants because they feel the procedure is quick, and the baby won't remember. Lack of supply is also an issue, with doses not being readily available worldwide creating an additional barrier to using sucrose.
"These challenges can be addressed," says Bueno, "By using clinical practice guidelines and locally developed evidence-based protocols, we can improve pain care in NICUs.
