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Denise Harrison RN, PhDChair in Nursing Care of Children, Youth & Families

Children's Hospital of Eastern Ontario (CHEO), CHEO Research Institute & University of Ottawa

Be Sweet to Babies: Breastfeeding, skin-to-skin care and sucrose for pain management

New BORN pain data elements

• Beginning April 7th 2014 – use of breastfeeding, skin-to-skin (kangaroo care) and sucrose during newborn screening/bilirubin levels added to the BORN database

Why add pain to BORN data ? BORN database and data collection processes

well established BORN data already used province-wide for

quality improvement purposes Use of effective pain management during

painful procedures is an important indicator of quality. Newborn screening – routine standardized

procedure that most infants have, and which is already collected as part of BORN data

Why add pain to BORN data ? Newborn screening – routine standardized – yet

painful procedure. The good news, is that effective pain

management strategies exist The bad news – studies continually show

infrequent use of pain management strategies during blood work for newborn infants Adding pain to BORN data – enables use of

data by individual units, and centrally – for quality improvement purposes

Pain Relief Measures During Newborn Screening or Serum Bilirubin [PPC,NICU]New pick list values: •Breastfeeding •Skin to skin•Sucrose•Other•None•Unknown

BIS Enhancements: Child Encounters

New BORN pain data elements

• What is the evidence to support these three key pain management strategies?

Showing the evidence

Breastfeeding for pain reduction

• 10 studies evaluated breastfeeding during heel lance (n=7) or venepuncture (n=3) in term infants (n = 1076 infants).

• Compared to infants having the procedures performed while in a cot, or while being held but not fed - breastfeeding resulted in reduced:o Behavioural responses (crying, facial expressions)o Composite pain scores o Heart rate changes from baseline

Shah et al. Breastfeeding or breast milk for procedural pain in newborns

Shah et al., Breastfeeding or breast milk for procedural pain in neonates. Cochrane Database of Systematic Reviews, 2012. DOI: 10.1002/14651858.CD004950.pub3.

How is breastfeeding analgesic?

• Combination of: o Suckling/food intakeo Skin to skin contacto Smell and movemento Pleasant tasteo Naturally occurring endorphins in breast milk (?)

Although breastfeeding is analgesic, small volumes of EBM are less effective

Challenges to practice Effectiveness & feasibility in sick infants is

questionable Practical challenges: Timing of bloods (middle of night or early in the AM?) Low chair/stool required for clinicians performing heel

lance/venepuncture

Beliefs: Infant will aspirate Procedure will take longer to perform Mother does not want to be there Infants will associate mother with painful procedure

Question

Do you/your unit consistently encourage and support mothers to

breastfeed their healthy babies during newborn screening or other

non-urgent blood draws?

Skin-to-skin care

(Kangaroo care)

Johnston et al., Skin-to-skin care (SSC) for procedural pain in neonates

• 19 published studies, including 1594 infants during heel lance (n=15), both heel lance and venepuncture (n=1), IM injection (n=3) in term (n=4) and preterm (n=15) infants

• SSC resulted in reduced:o Behavioural responses and pain scores compared to

placebo/no treatmento Conflicting results when compared to sucrose/glucose o Physiological responses variable

Johnston et al., Skin-to-skin care for procedural pain in neonates. Cochrane Database of Systematic Reviews, 2014 DOI: 10.1002/14651858.CD008435.pub2.

How is skin-skin care analgesic?

• Tactile stimulation• Smell of mother’s milk• Sight of mother • Sound of mother’s voice• Movement/Rocking• Heart beat

Ineffective without the mother

Effectiveness of:

Fathers?

Other women?

Twin?

‘Enhanced’ skin-to-skin?

Addition of sucrose/glucose?

Challenges to practice Feasibility & practical challenges:

Timing of bloods (middle of night or early in the AM?) Low chair/stool required for clinicians performing heel

lance/venepuncture Feasibility, effectiveness and safety for:

Extremely pre-term infants? Sick infants? Post-operative infants?

Beliefs: Procedure will take longer to perform Mother does not want to be there Infants will associate mother with painful procedure

Question

Do you/your unit consistently encourage mothers to do SSC with

their preterm infants during newborn screening or other non-urgent blood

draws?

Sucrose is the most extensively studied intervention to decrease pain in infants

Sucrose

Systematic Reviews

Systematic Review Author & Details # Trials # Participants

Sucrose for newborn infants Stevens et al. 2013 57 4,730 infants

Non- Sucrose for newborn infants (mainly glucose) Bueno et al. 2013 38 3,785 infants

Glucose solutions in infants Kassab et al. 2012 18 2,562 infants

Sweet solutions for infants (1-12 months ) Kassab et al. 2012 14 1,551 infants

Sweet solutions for infants(1-12 months) Harrison et al. 2010 14 1,618 infants

Sweet solutions for children Harrison et al. 2011 4 330 children

Sucrose in newborn infantsStevens et al, 2013. 57 studies with 4,730 infants

Key Findings‐ Sucrose significantly reduced crying duration and PIPP

scores during short lasting painful procedures‐ Inconsistent reduction in physiological responses‐ Sucrose did not significantly reduce PIPP scores during

retinopathy of prematurity(ROP) eye examinations – a procedure of longer duration

• PIPP= Premature Infant Pain Profile

Stevens et al. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database of Systematic Reviews, 2013. DOI: 10.1002/14651858.CD001069.pub4.

Non-sucrose in newborn infantsBueno et al, 2013. 38 studies with 3,785 infants

Key Findings- Non sucrose solutions (mainly 20%-30% glucose)

significantly reduced crying duration and PIPP scores - Less reduction of physiological responses- Safe and effective for reducing procedural pain from

single events

Bueno et al., A systematic review and meta-analyses of non-sucrose sweet solutions sucrose for pain relief in neonates. Pain Res Manag, 2013. 18(3): p. 153-161.

How is sweet taste analgesic?

Thought to be 2 mechanisms

1. Attention gaining response to strong sweettaste

2. ? Release of endogenous opioids:• Peak effects at around 2 minutes in newborns

– shorter in older infants• ? Not effective if given narcan, as narcan

competes for the same receptor sites

Analgesic effects of sweet solutions –too much evidence?

• 203 identified published trials of sweet solutions in human infants

• Placebo or no-treatment groups:

= 181 (90%)

Combined cumulative meta-analysis of sweet solutions for newborn infants

• Includes sucrose, glucose, other sweet tasting solutions

• Pooled results for crying time (mean difference) and pain scores (standardized mean difference) for all procedures/all solutions

Study name Year Cumulative std diff in means (95% CI)

Lower Upper Point limit limit

Carbajal R 1999 1999 -0.53 -1.10 0.03Eriksson M 1999a 1999 -1.01 -1.94 -0.07Eriksson M 1999b 1999 -0.93 -1.48 -0.38Ramenghi LA 1999 1999 -0.95 -1.41 -0.50Stevens, B. 1999 1999 -0.78 -1.26 -0.29Ahuja VK 2000 2000 -0.72 -1.15 -0.29Bellieni CV 2001 2001 -0.72 -1.13 -0.32Carbajal, R. 2002 2002 -0.70 -1.06 -0.35Gibbins, S. 2002 2002 -0.70 -0.98 -0.42Gradin M 2002 2002 -0.63 -0.89 -0.37Carbajal R 2003 2003 -0.83 -1.24 -0.41Harrison D 2003 2003 -0.79 -1.16 -0.43Xia 2003 2003 -0.78 -1.11 -0.46Ackam M 2004a 2004 -0.81 -1.12 -0.50Ackam M 2004b 2004 -0.84 -1.14 -0.54Bauer K 2004 2004 -0.89 -1.19 -0.59Mitchell, A. 2004 2004 -0.90 -1.18 -0.61Gal, P. 2005 2005 -0.88 -1.15 -0.60Grabska, J 2005 2005 -0.83 -1.10 -0.56Ling JM 2005 2005 -0.84 -1.10 -0.58Ogawa, S 2005a 2005 -0.83 -1.08 -0.59Ogawa, S 2005b 2005 -0.81 -1.05 -0.58Ahn HY 2006 2006 -0.81 -1.04 -0.58Boyle, E. M 2006 2006 -0.80 -1.02 -0.58Mathai S 2006 2006 -0.78 -1.00 -0.57Gharehbaghi MM 2007 2007 -0.85 -1.09 -0.62Okan F 2007 2007 -0.83 -1.07 -0.60Bonetto G 2008 2008 -0.81 -1.04 -0.59Freire NBS 2008 2008 -0.83 -1.05 -0.61Taddio, A 2008 2008 -0.83 -1.04 -0.62Axelin A 2009 2009 -0.83 -1.04 -0.63Chermont AG 2009 2009 -0.80 -1.02 -0.58Chen 2009 2009 -0.79 -1.00 -0.59Huang 2009 2009 -0.83 -1.04 -0.62Slater, R. 2010 2010 -0.83 -1.03 -0.62Chen 2010 2010 -0.84 -1.04 -0.64Qian 2010 2010 -0.85 -1.05 -0.65Kristof ferson L 2011 2011 -0.85 -1.05 -0.66Li 2011 2011 -0.89 -1.10 -0.69Lu 2011 2011 -0.91 -1.11 -0.71Zhao 2012 2011 -1.01 -1.26 -0.77Zhou 2011 2011 -1.00 -1.23 -0.76Zhang 2012 2012 -0.99 -1.23 -0.76Costa MC 2013 2013 -1.01 -1.24 -0.78Nimbalkar, S. 2013 2013 -0.99 -1.21 -0.76

-0.99 -1.21 -0.76-2.00 -1.00 0.00 1.00 2.00

Favours A Favours B

Sucrose/Glucose Water

Standardized mean

pain scores

(Harrison et al. Unpublished data)

Question

Do you/your unit consistently use sucrose or glucose (if mothers

cannot breastfeed or SSC) - during newborn screening or other non-

urgent blood draws?

What sweet solutions do NOT do• Effectively reduce pain during prolonged and

procedures such as eye examination

• Consistently reduce physiological responses•

• Reduce EEG response (Norman et al, 2008, Slater et al, 2010)

o Mechanismso Effectiveness in combination with other

interventionso Minimal effective volume required o Effectiveness in young children aged 1-3 yearso Does consistent use of sucrose OR

breastfeeding or SSC during bloodwork improve long-term outcomes

Remaining knowledge gaps

Sucrose Barriers Availability & Accessibility?

Sucrose Myths

Harrison. Oral sucrose for pain management in infants: myths and misconceptions. J Neonat Nurs. 2008;14:39-46

Myth busting the oral sucrose myths1 Not “baby friendly” Busted

2 Grows bacteria Busted

3 Risk of dental caries ?

4 Poor neurological outcomes in infants <32 weeks

Busted

5 Increases risk of NEC Busted

6 Hyperglycaemia Busted

7 Not effective in older babies Busted but effectssmaller

8 Development of tolerance Busted when used appropriately

Moving evidence into practice - Addressing barriers at all levels

Putting evidence into consistent clinical practiceWorking with nurses, physicians,

phlebotomists, lab technicians, unit managers etcWorking with parents Requirement for documentation

The CHALLENGES

DOCUMENTATION DOCUMENTATION DOCUMENTATION

The babies get older…

Infant Vaccination - the secret

Contact: dharrison@cheo.on.ca

Be Sweet to Babies During Painful Procedures

Acknowledgments Be Sweet to Babies Team CHEO Foundation CHEO RI Sandy Dunn (BORN)

BORN is hosting a two-day conference to bring health care providers, policy makers, health administrators, educators, quality and risk management leaders, and researchers together to share experiences, enhance knowledge, foster partnerships, and promote research.

www.bornontarioconference.ca

Join the conversation!

Thank you for attending BORN Provincial Rounds.