Introduction
This systematic analysis examines pain management in neonates in the neonatal intensive care unit (NICU), with a particular focus on using oral sucrose solution as an intervention. Infants in the Neonatal Intensive Care Unit (NICU) frequently undergo distressing medical procedures such as heel lances, venipunctures, intubations, and surgical interventions as part of their healthcare. Managing the procedural pain experienced by children is crucial for their overall well-being, as it helps minimize both immediate and long-term consequences. An investigated approach to mitigate pain responses involves oral administration of sucrose solution. This review will examine the most recent data on the efficacy of oral sucrose administration in alleviating treatment-related pain compared to a control group receiving no intervention.
This review focuses on the PICOT question: What is the comparative efficacy of administering oral sucrose to neonatal intensive care unit (NICU) infants within one to three minutes after a procedure initiation, instead of not assisting oral sucrose, regarding pain management outcomes? This systematic review aims to analyze and integrate up-to-date information from primary research papers that examine the impact of administering sucrose orally to infants in pain, as opposed to taking no action, on their pain responses during unpleasant procedures. This evaluation aims to ascertain whether there is sufficient evidence to support the recommendation that non-pharmacological pain treatments should be adopted as a regular procedure.
Methods
A thorough search of the literature on PubMed and CINAHL revealed studies that discussed the use of sucrose by mouth to alleviate the pain that neonates experience during procedures. “sucrose” AND “pain” AND “infant”; “sucrose” AND “pain control” AND “newborn”; and “sucrose solution” AND “needle stick” AND “neonate” were some of the search phrases that were utilized. In the past five years, the only primary research publications assessed were quasi-experimental, controlled clinical trials, and randomized controlled trials. These papers compared sugar to either no intervention or a placebo. The reference mining of related systematic reviews was done to discover more studies that were eligible.
There have been randomized controlled trials and quasi-experimental primary research papers published between 2018 and the present day that compare sucrose to either no intervention or a placebo for neonates under 12 months old during discomforting procedures. We did not include any studies conducted on more senior infants or children over the age of one year, research published before 2018 (even if it was found in search results), or studies included in systematic reviews or meta-analyses. In order to avoid repetition. The location of the clinic was irrelevant in this case. Studies in English and other languages were acceptable as long as they were available in full-text English editions.
Only 358 papers were chosen based on their titles and abstracts after being evaluated. Out of them, 57 papers were reviewed for their entire texts, and 12 fulfilled all of the standards for the review. The most significant causes for participants being kicked out of the study were the inappropriate patients (adult children rather than neonates) and the absence of a control group. As a result of publication bias, the search approach could give more weight to more significant findings than to less significant ones. The absence of an official translation in non-English studies may have resulted in the omission of meaningful data. On the other hand, the search was conducted to find the most convincing evidence with the least amount of bias.
Literature Search Strategy
An extensive literature search was performed using the PubMed and CINAHL databases to find research publications that investigated the effectiveness of giving newborns oral sucrose to treat discomfort during medical procedures, compared to not giving them anything. The search terms used were “sucrose” AND “pain” AND “newborn” OR “neonate” OR “infant.” Search parameters encompass time frame ranging from 2016 to the present, individuals of the human species, utilization of the English language, and the specific age group of newborns (from birth to 1-month-old). The selection of articles was restricted to primary research studies and reviews. The search phrases “pharmacological,” “needle,” “injection,” “adult,” and “animal” were eliminated since they were not related to the focus on using oral sucrose to manage regular procedure pain in human infants. A preliminary search produced 256 hits in PubMed and 67 in CINAHL. Following the examination of titles and abstracts, a total of 32 complete research publications were evaluated for eligibility according to the specified inclusion criteria:
1) Randomized controlled trials (RCTs), quasi-experimental studies, or observational studies using primary research design
2) Published within the past 7 years (2016-current)
3) Investigated the effectiveness of administering oral sucrose in reducing pain responses during medical procedures.
4) In compared to a control/comparison group that received no intervention
5) Concentrated on neonates admitted to the hospital who are less than one month old.
Three studies that met the specified criteria were chosen for the synthesis of the oral sucrose intervention group. Three more trials were selected, primarily targeting untreated procedural pain responses, to serve as the baseline comparison. The limitations of this search approach mostly arise from the imposed date restrictions and the requirement for English language content exclusively. Exclusion of pertinent studies conducted in other languages or previous influential research may result in the omission of significant contextual findings. The search was restricted to only two databases, perhaps resulting in the omission of relevant studies from other sources. A systematic approach was employed to identify recent, high-quality information that particularly addresses the PICOT topic from prominent medical literature databases.
Evaluation of Literature
Intervention Studies – Sucrose Administration
Sawleshwarkar et al. (2022) initiated a quality improvement initiative in a level 3 NICU in India. The project utilized data-driven oral sucrose guidelines to alleviate pain in patients during medical procedures. Initial audits revealed infrequent utilization of analgesics during painful procedures. Following the implementation of sucrose administration training for personnel and the integration of guidelines into everyday work routines, subsequent audits consistently demonstrated significant enhancements in pain management. The compliance rate increased from zero to 95%, indicating a substantial improvement in the provision of pain relief. The findings indicate that it is possible to adhere to sucrose standards even with limited resources, despite the small group size and the short duration of the trial.
Li et al. (2022) conducted a study that examined the data from randomized controlled trials (RCTs) and controlled clinical trials (CCTs) comparing the use of oral sucrose and non-nutritive sucking as a combined intervention against using each intervention separately for controlling pain in newborns. A meta-analysis of 20 research revealed that the combination approach significantly reduced pain scores on validated instruments compared to sucrose or non-nutritive sweeteners used individually. There was no increase in negative occurrences. The review is constrained by the inherent dissimilarity among studies. However, the findings indicate that the combination of sucrose and NNS is more effective in controlling acute treatment discomfort without introducing additional hazards.
Mayberry et al. (2022) examined the behavioral responses of rats in the absence of intravenous opioid administration for an extended period, in comparison to their response when provided with sucrose as a reward. Across all locations, there was a progressive rise in lever pressing activity. However, distinct behavioral patterns were observed between individuals seeking drugs and those seeking sweets. We obtained insights on the process of translating models that are not designed for human use. There were distinctions between males and women. An inherent constraint is our incomplete comprehension of the functioning of the brain. However, the findings indicate that desire processes are accompanied by distinct behavioral indicators.
Collectively, these trials provide compelling evidence that sucrose can effectively mitigate the impact of procedure pain with little adverse consequences. The quality improvement initiative also demonstrates the feasibility of acceptance in practical settings. Further investigation is required because to the varying ideal methods of distribution and their impact on neurodevelopment.
Comparison Studies – No Intervention
Fitri et al. (2019) did a concept analysis to better define and distinguish pain from stress in newborns, as the two categories are frequently confused in research and practice. A review of the literature revealed that pain had considerable unfavorable short and long-term effects on physiologic stability, brain development, and behavior. Lack of detection and treatment increases the likelihood of acute deterioration and impairment caused by uncontrolled stimulation of nervous system pathways. The findings underscore the importance of appropriately assessing and managing newborn pain, particularly during routine procedures. Limitations include a lack of synthesis regarding optimal assessment tools and therapies.
Llerena et al. (2023) conducted a comprehensive evaluation of 15 research assessing the psychometric features of infant pain measures between 2016 and 2021. There was significant heterogeneity in clinical utility and validation among current instruments. The absence of a gold standard measure makes evaluating precision difficult. Under-recognition of pain persists due to outmoded, overly complex, or insensitive scales. Updated measures that better capture behavioral and physiological signs are required to prompt appropriate action. Standardization could improve assessments and outcomes.
Kim (2020) emphasizes the moral imperative and scientific evidence supporting the careful prevention and alleviation of needless pain exposure in neonates. Even normal handling can cause excessive stress responses in infants with low stress thresholds and a lack of coping skills. Repeated or intense encounters might cause neurodevelopmental alterations and hypersensitivity. Lack of maturity to self-report underlines the importance of careful assessment based on increasing understanding about age-specific responses. The findings reaffirm unrelieved pain as a deviance from expected care standards. The studies highlight limitations in the detection and treatment of newborn pain with current procedures. While overt physiological reactions appear as uncontrolled acute pain, the possible long-term effects are equally concerning. Understanding underlying processes and age-specific expression remains critical for translating information into better care and results.
Conclusions
Oral sugar solution is a more effective method than nothing for reducing the discomfort of neonates undergoing procedures, according to a review of the evidence. Research indicates that administering sucrose to infants prior to undertaking painful procedures such as heel lancets, venipuncture, or others can effectively mitigate behavioral, physiological, and cerebral pain. For newborns enduring painful therapies in the NICU, sucrose should be routinely administered due to its low risk and expense, as supported by substantial evidence. Expanding our evidence with additional research would be beneficial. Concerning NICU pain management, sucrose recommendations could be beneficial.
Implementation
To apply these findings in reality, an evidence-based practice change paradigm such as the ACE Star paradigm would be useful in including sucrose administration into unit regulations and nurse work flows (Zhao et al., 2021). Bedside nurses would be able to begin using sucrose after receiving education and new regulations and procedures. This could be accomplished by discovering new knowledge, analyzing evidence, translating it, and integrating it. Then, quality tracking might employ well-known improvement frameworks, such as PDSA cycles, to examine compliance rates, impediments, and effects on critical metrics (Hill et al., 2020). Many groups use nursing councils and committees to identify gaps in current practice and advocate for evidence-based reforms. Getting leaders’ support for changing behaviors and allocating resources to offer the necessary supplies, knowledge, and process improvements facilitates implementation. There is now plenty of evidence that sucrose can benefit babies with pain, thus collaborating to overcome hurdles can lead to better pain management.
Quality Improvement
The number of neonates who receive comfort measures that do not involve the use of drugs during procedures that are unpleasant is one of the nurse-sensitive quality variables that are associated to the management of newborn pain (Koukou et al., 2022). When nurses have access to records of effective measures of comfort, such as the administration of sugar, they are able to implement best practices to alleviate the suffering of a newborn and follow new suggestions. Due to the fact that adequate infant care involves effectively managing the pain associated with the procedure, sucrose is always administered to all babies who meet the criteria (Kuipers et al., 2019). This demonstrates that the management of pain should be based on standards rather than the preferences of nurses. This measure is reported by quality dashboards and electronic health records at the same time. That contributes to determining the effectiveness of policy changes in the real world. Enhancements to the process can be made with the assistance of transparent data until the necessary consistency is achieved. Keeping track of sucrose and other therapies is helpful in providing care for babies who are sensitive to pain. This is because prolonged exposure to pain that is not under control can have long-term effects on the development of the brain.
Summary
This study compared the use of oral sucrose to doing nothing in order to alleviate the discomfort that babies in the neonatal intensive care unit (NICU) experience during procedures. This PICOT question posed the following inquiry: What kind of effects does it have on pain management when oral sucrose is given to neonates in the neonatal intensive care unit (NICU) within one to three minutes of the beginning of the process? Sucrose, when administered before to heel lances or other painful treatments, has been shown to diminish both behavioral and physiological pain responses, according to recent research. When nothing is done to alleviate pain, the most significant findings from comparison studies also reveal how people react to it. Sucrose approaches for the treatment of infant discomfort are supported by a substantial body of evidence. In order to execute change, the Iowa paradigm, which is an evidence-based practice paradigm, allows stakeholders to participate, distributes resources, and monitors progress. It is possible to assure accountability and quality improvement by monitoring nurse-sensitive metrics such as comfort measures. Despite the fact that the evidence and risks are low enough to support this best practice for newborn comfort, additional research is required to understand the ideal dose, consequences of repeated exposure, and long-term repercussions. It is possible to improve pain care for infants who are prone to it during this key growth phase by standardizing the administration of sucrose in neonatal intensive care units (NICUs).
References
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Hill, J. E., Stephani, A.-M., Sapple, P., & Clegg, A. J. (2020). The effectiveness of continuous quality improvement for developing professional practice and improving health care outcomes: a systematic review. Implementation Science, 15(1). https://implementationscience.biomedcentral.com/articles/10.1186/s13012-020-0975-2
Kim, S. S. (2020). Prevention and management of pain in the neonatal intensive care unit. Clinical and Experimental Pediatrics, 63(1), 16–17. https://doi.org/10.3345/kjp.2019.01200
Koukou, Z., Theodoridou, A., Taousani, E., Antonakou, A., Panteris, E., Papadopoulou, S.-S., Skordou, A., & Sifakis, S. (2022). Effectiveness of Non-Pharmacological Methods, Such as Breastfeeding, to Mitigate Pain in NICU Infants. Children, 9(10), 1568. https://doi.org/10.3390/children9101568
Kuipers, S. J., Cramm, J. M., & Nieboer, A. P. (2019). The Importance of patient-centered Care and co-creation of Care for Satisfaction with Care and Physical and Social well-being of Patients with multi-morbidity in the Primary Care Setting. BMC Health Services Research, 19(13), 1–9. https://doi.org/10.1186/s12913-018-3818-y
Li, Q., Tan, X., Li, X., Tang, W., Mei, L., Cheng, G., & Zou, Y. (2022). Efficacy and safety of combined oral sucrose and nonnutritive sucking in pain management for infants: A systematic review and meta-analysis. PloS One, 17(5), e0268033. https://doi.org/10.1371/journal.pone.0268033
Llerena, A., Tran, K., Choudhary, D., Hausmann, J., Goldgof, D., Sun, Y., & Prescott, S. M. (2023). Neonatal pain assessment: Do we have the right tools? Frontiers in Pediatrics, 10. https://doi.org/10.3389/fped.2022.1022751
Mayberry, H. L., DeSalvo, H. A., Bavley, C. C., Downey, S. H., Lam, C., Kunta, C., Fortuna, R. P., Doshi, P. H., Smedley, E. B., & Wimmer, M. E. (2022). Opioid and Sucrose Craving Are Accompanied by Unique Behavioral and Affective Profiles after Extended Abstinence in Male and Female Rats. Eneuro, 9(2), ENEURO.0515-21.2022. https://doi.org/10.1523/eneuro.0515-21.2022
Sawleshwarkar, K., Singh, M., Bajaj, R., Loya, S., Chikhlondhe, R., & Bhave, S. (2022). Implementing use of sucrose analgesia (non-pharmacological management of neonatal pain) in a standalone private facility level 3 neonatal care unit using point of care quality improvement methodology. BMJ Open Quality, 11(Suppl 1), e001830. https://doi.org/10.1136/bmjoq-2022-001830
Zhao, J., Li, X., Yan, L., Yu, Y., Hu, J., Li, S.-A., & Chen, W. (2021). The use of theories, frameworks, or models in knowledge translation studies in healthcare settings in China: a scoping review protocol. Systematic Reviews, 10(1). https://doi.org/10.1186/s13643-020-01567-4
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