Dear Sir,
Losacco et al's1 review of practice across European neonatal units
regarding the use of non-pharmacological analgesia for painful procedures
in neonatal units has highlighted the relatively infrequent use of these
techniques. This is despite good evidence confirming the effectiveness of
non-pharmocolgical analgesia2 and evidence of deleterious effects of pain
on babies both in short term3 (decreased oxygenation, haemodynamic
instability, and raised intracranial pressure) and long term4
(neurodevelopmental delay and altered perceptions of pain in later life).
We have recently conducted an audit on the use of non-pharmacological
analgesia for neonates, comparing our current practice at Good Hope
Hospital, Birmingham, UK against our hospital guidelines. As a part of
this process we have also carried out a review of literature on use of non
-pharmacologic analgesia and assessed if the current hospital guidance
meets evidence based recommendations.
Clinical staff in various neonatal and paediatric clinical areas at
Good Hope Hospital were requested to fill in questionnaires every time
they carried out a painful procedure in an infant. 46 questionnaires were
filled in total; 8 from the postnatal wards, 11 from the childrens'
assessment unit or paediatric ward, and 27 from the neonatal unit.
Ages on postnatal wards for which procedures were carried out ranged
from day 1 to 4. Five of the 8 babies were given sucrose (0.6ml of 24%
solution) which had to be brought up from the neonatal unit, since there
is none available on the postnatal wards. In 2 of the 5 babies additional
non-pharmacological analgesic (NPA) methods were employed (swaddling and
breastfeeding). 2 of the babies not given sucrose were swaddled
Ages for the childrens' assessment unit and paediatric ward ranged
from 2 days to 4 months (the maximum age). 2 of the 11 children were given
sucrose which had to be brought up from the neonatal unit, both were
having a lumbar puncture. One was given 1.3ml of 24% sucrose since the
procedure was prolonged, 3 aliquots of 0.6ml, 0.4ml and 0.3ml were given.
The other was given 0.6ml of 24% solution. For both, additional non-
pharmacological analgesic methods were employed, swaddling for both, and a
dummy for one. 3 of the 11 children were not given sucrose because it was
not available, but additional methods were used (swaddling, breastfeeding
and dummy) for heel pricks and venipuncture. The other 6 babies received
no form of analgesia, procedures included 2 lumbar punctures.
In the neonatal unit the ages ranged from 33+2 weeks gestational age
(our unit only keeps babies above 32 weeks), to 1 month post term-birth
age. 24 of the 27 babies from the neonatal unit received sucrose (0.4ml -
1ml of 24% solution). 18 of the 24 received additional non-pharmacological
analgesia (swaddling, dummy, or both). 6 of the 24 received just sucrose.
3 of the 27 babies did not receive sucrose. One was undergoing the Guthrie
test, the reasoning was it would not take very long to carry out the
procedure, and the baby was swaddled and given a dummy. 1 of the other
babies was nil-by-mouth and so not given sucrose, and the last one was
being given an intramuscular vaccination (Hep B) and the administrator had
the honesty to write they didn't give sucrose, and are not quite sure why
they didn't.
So out of 46 babies who were eligible for sucrose it was given to 31
(~67%), but if considering the neonatal unit alone, this rises to ~92% (24
out of 26 babies). Non-pharmacological analgesic methods were used in
fewer infants (28 out of 46; ~61%) but again, this was used relatively
more often in the neonatal unit (19 out of 27; ~70%). The main reason
given for not using sucrose was its unavailability.
Examination of the literature to produce evidence based hospital
guidelines revealed effective use of non-pharmacological analgesia in the
pre- and post-neonatal period. Hatfield5 et al. used sucrose and non-
nutritive sucking in 100 infants of 2 and 4 months of age undergoing
routine vaccinations in the US, and compared to controls receiving water.
They used the University of Wisconsin Children's Hospital (UWCH) pain
scale to assess pain response at 2, 5, 7 and 9 minutes post vaccinations,
and found a significant difference at each of these time markers with use
of 0.6ml/kg of 24% sucrose. This being just one example, there is
therefore evidence of effective analgesia using sucrose and non-nutritive
sucking for neonates of all gestational ages2 and up to the age of 4
months (even if the efficacy decreases with age requiring higher
concentrations and amounts of sucrose). If the mother and baby are willing
to breastfeed the combination of maternal body contact, so visual, tactile
and olfactory stimuli, breastmilk and suckling on a nipple, are found to
be as effective as sucrose and non-nutritive sucking;6,7 and in low
gestation and/or sick neonates positional forms of analgesia, e.g. prone
positioning, facilitated tucking, swaddling; are found to be especially
effective.8
Since the aim is for effective analgesia in infants of this age, it
would make sense for such resources to be available in all clinical areas
where such procedures are undertaken. In our audit we found this was not
the case, even though babies who may be only a few days old are exposed to
heel-pricks or venipuncture in post-natal wards, or present to children's
assessment units from home, the neonatal unit was the only clinical area
in which sucrose was available and the analgesic guideline was in place.
This was also true for the other hospital within the Heart of England NHS
foundation trust; Birmingham Heartland's Hospital. Combined with the
healthcare staffs' lack of knowledge of effective use of other forms of
non-pharmacological analgesia, this meant such infants received no form of
pain relief compared to babies of similar ages in the neonatal unit where
sucrose is available and neonatal nurses try to ensure concurrent use of
other analgesic methods.
So whereas Losacco et al. found poor compliance with use of analgesic
methods in very low birth weight infants in countries across Europe, we
would argue the problem is larger than that. There needs to be a program
of education for staff working with neonates of all gestational ages and
babies in the first few months of life covering why analgesia is important
at this early age, what methods we have in place which work and how they
are effective, alone or in conjunction. Furthermore, resources (e.g.
sucrose) need to be available in all clinical areas where infants of this
age range receive treatment.
References
1. Losacco V, Cuttini M, Greisen G, et al. Heel blood sampling in European
neonatal intensive care units: compliance with pain management guidelines.
Arch Dis Child Fetal Neonatal Ed 2011; 96: F65-F68.
2. Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in newborn
infants undergoing painful procedures. Cochrane Database Syst Rev 2010; 1:
CD001069.
3. Anand KJS, Hickey PR. Pain and its effects in the human neonate and
fetus. N Engl J Med 1987;317:1321?9.
4. Grunau RV, Holsti L, Peters JW. Long-term consequences of pain in human
neonates. Semin Fetal Neonatal Med. 2006;11(4): 268-275.
5. Hatfield LA., Gusie ME., Dyer AM., Polomano RC. Analgesic Properties of
Oral Sucrose During Routine Immunizations ar 2 and 4 Months of Age.
Pediatrics 2008; 121; e327-e334.
6. Carbajal R, Veerapen S, Couderc S, Jugie M, Ville Y. Analgesic effect
of breast feeding in term neonates: randomised controlled trial. Br Med J
2003;326:13.
7. Gradin M, Finnstrom O, Schollin J. Feeding and oral glucose- additive
effects on pain reduction in newborns. Early Hum Dev 2004;77:57-65.
8. Prasopkittikun T, Tilokskulchai F. Management of pain from heel stick
in neonates. An analysis of research conducted in Thailand. J Perinat
Neonat Nurs 2003;7:304-12.
Conflict of Interest:
None declared
Dear Sir,
Losacco et al's1 review of practice across European neonatal units regarding the use of non-pharmacological analgesia for painful procedures in neonatal units has highlighted the relatively infrequent use of these techniques. This is despite good evidence confirming the effectiveness of non-pharmocolgical analgesia2 and evidence of deleterious effects of pain on babies both in short term3 (decreased oxygenation, haemodynamic instability, and raised intracranial pressure) and long term4 (neurodevelopmental delay and altered perceptions of pain in later life).
We have recently conducted an audit on the use of non-pharmacological analgesia for neonates, comparing our current practice at Good Hope Hospital, Birmingham, UK against our hospital guidelines. As a part of this process we have also carried out a review of literature on use of non -pharmacologic analgesia and assessed if the current hospital guidance meets evidence based recommendations.
Clinical staff in various neonatal and paediatric clinical areas at Good Hope Hospital were requested to fill in questionnaires every time they carried out a painful procedure in an infant. 46 questionnaires were filled in total; 8 from the postnatal wards, 11 from the childrens' assessment unit or paediatric ward, and 27 from the neonatal unit.
Ages on postnatal wards for which procedures were carried out ranged from day 1 to 4. Five of the 8 babies were given sucrose (0.6ml of 24% solution) which had to be brought up from the neonatal unit, since there is none available on the postnatal wards. In 2 of the 5 babies additional non-pharmacological analgesic (NPA) methods were employed (swaddling and breastfeeding). 2 of the babies not given sucrose were swaddled
Ages for the childrens' assessment unit and paediatric ward ranged from 2 days to 4 months (the maximum age). 2 of the 11 children were given sucrose which had to be brought up from the neonatal unit, both were having a lumbar puncture. One was given 1.3ml of 24% sucrose since the procedure was prolonged, 3 aliquots of 0.6ml, 0.4ml and 0.3ml were given. The other was given 0.6ml of 24% solution. For both, additional non- pharmacological analgesic methods were employed, swaddling for both, and a dummy for one. 3 of the 11 children were not given sucrose because it was not available, but additional methods were used (swaddling, breastfeeding and dummy) for heel pricks and venipuncture. The other 6 babies received no form of analgesia, procedures included 2 lumbar punctures.
In the neonatal unit the ages ranged from 33+2 weeks gestational age (our unit only keeps babies above 32 weeks), to 1 month post term-birth age. 24 of the 27 babies from the neonatal unit received sucrose (0.4ml - 1ml of 24% solution). 18 of the 24 received additional non-pharmacological analgesia (swaddling, dummy, or both). 6 of the 24 received just sucrose. 3 of the 27 babies did not receive sucrose. One was undergoing the Guthrie test, the reasoning was it would not take very long to carry out the procedure, and the baby was swaddled and given a dummy. 1 of the other babies was nil-by-mouth and so not given sucrose, and the last one was being given an intramuscular vaccination (Hep B) and the administrator had the honesty to write they didn't give sucrose, and are not quite sure why they didn't.
So out of 46 babies who were eligible for sucrose it was given to 31 (~67%), but if considering the neonatal unit alone, this rises to ~92% (24 out of 26 babies). Non-pharmacological analgesic methods were used in fewer infants (28 out of 46; ~61%) but again, this was used relatively more often in the neonatal unit (19 out of 27; ~70%). The main reason given for not using sucrose was its unavailability.
Examination of the literature to produce evidence based hospital guidelines revealed effective use of non-pharmacological analgesia in the pre- and post-neonatal period. Hatfield5 et al. used sucrose and non- nutritive sucking in 100 infants of 2 and 4 months of age undergoing routine vaccinations in the US, and compared to controls receiving water. They used the University of Wisconsin Children's Hospital (UWCH) pain scale to assess pain response at 2, 5, 7 and 9 minutes post vaccinations, and found a significant difference at each of these time markers with use of 0.6ml/kg of 24% sucrose. This being just one example, there is therefore evidence of effective analgesia using sucrose and non-nutritive sucking for neonates of all gestational ages2 and up to the age of 4 months (even if the efficacy decreases with age requiring higher concentrations and amounts of sucrose). If the mother and baby are willing to breastfeed the combination of maternal body contact, so visual, tactile and olfactory stimuli, breastmilk and suckling on a nipple, are found to be as effective as sucrose and non-nutritive sucking;6,7 and in low gestation and/or sick neonates positional forms of analgesia, e.g. prone positioning, facilitated tucking, swaddling; are found to be especially effective.8
Since the aim is for effective analgesia in infants of this age, it would make sense for such resources to be available in all clinical areas where such procedures are undertaken. In our audit we found this was not the case, even though babies who may be only a few days old are exposed to heel-pricks or venipuncture in post-natal wards, or present to children's assessment units from home, the neonatal unit was the only clinical area in which sucrose was available and the analgesic guideline was in place. This was also true for the other hospital within the Heart of England NHS foundation trust; Birmingham Heartland's Hospital. Combined with the healthcare staffs' lack of knowledge of effective use of other forms of non-pharmacological analgesia, this meant such infants received no form of pain relief compared to babies of similar ages in the neonatal unit where sucrose is available and neonatal nurses try to ensure concurrent use of other analgesic methods.
So whereas Losacco et al. found poor compliance with use of analgesic methods in very low birth weight infants in countries across Europe, we would argue the problem is larger than that. There needs to be a program of education for staff working with neonates of all gestational ages and babies in the first few months of life covering why analgesia is important at this early age, what methods we have in place which work and how they are effective, alone or in conjunction. Furthermore, resources (e.g. sucrose) need to be available in all clinical areas where infants of this age range receive treatment.
References 1. Losacco V, Cuttini M, Greisen G, et al. Heel blood sampling in European neonatal intensive care units: compliance with pain management guidelines. Arch Dis Child Fetal Neonatal Ed 2011; 96: F65-F68. 2. Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev 2010; 1: CD001069. 3. Anand KJS, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med 1987;317:1321?9. 4. Grunau RV, Holsti L, Peters JW. Long-term consequences of pain in human neonates. Semin Fetal Neonatal Med. 2006;11(4): 268-275. 5. Hatfield LA., Gusie ME., Dyer AM., Polomano RC. Analgesic Properties of Oral Sucrose During Routine Immunizations ar 2 and 4 Months of Age. Pediatrics 2008; 121; e327-e334. 6. Carbajal R, Veerapen S, Couderc S, Jugie M, Ville Y. Analgesic effect of breast feeding in term neonates: randomised controlled trial. Br Med J 2003;326:13. 7. Gradin M, Finnstrom O, Schollin J. Feeding and oral glucose- additive effects on pain reduction in newborns. Early Hum Dev 2004;77:57-65. 8. Prasopkittikun T, Tilokskulchai F. Management of pain from heel stick in neonates. An analysis of research conducted in Thailand. J Perinat Neonat Nurs 2003;7:304-12.
Conflict of Interest:
None declared