Effect of 24% Oral Sucrose in Pain Reduction during Venipuncture in Neonates

Rashmita Sethi¹, Geetarani Nayak²

¹Lecturer, Viswas College of Nursing, Bhubaneswar

²Asst. Professor, SUM Nursing College, S’O’A University, Bhubaneswar

*Corresponding Author Email: geetaraninayaks@yahoo.com, smitarasmi@gmail.com

ABSTRACT:

Neonates frequently undergo various painful procedures without analgesia and routinely experienced pain in the Neonatal Intensive Care Unit. The issue of pain management among new born has been largely neglected and commonly overlooked in most of the clinical settings can lead to long term adverse consequences and deleterious effect. Administrating sucrose before painful procedure like venipuncture can relief pain in new born. The present study was carried out in (NICU) of IMS and SUM Hospital, Bhubaneswar with the purpose to determine the effect of 24% oral sucrose administration on pain reduction during venipuncture. 30 neonates undergoing venipuncture were selected through purposive sampling. The pain level was assessed by using Neonatal Infant Pain Scale (NIPS) with routine care during venipuncture and then same neonates were administered 24% sucrose solution orally just 2 minutes before undergoing venipuncture second time. A highly significant reduction of pain during venipuncture in experimental group was observed at (p<0.001, t=9.38).

KEYWORDS: Effect, 24% oral sucrose, Venipuncture, Neonatal and Pain

INTRODUCTION:

Pain is an unpleasant sensory and emotional experience associated with actual or potential injury to the tissue.¹,² Newborns are more sensitive to pain in comparison to older children and adults. The critically ill newborns those who are admitted in Neonatal Intensive Care Unit (NICU) frequently undergo through various painful procedures.

It is often associated with anxiety, avoidance, and parental distress. Despite the magnitude of effects of pain on newborn, it is most commonly under recognized, under treated and overlooked. Inadequate pain management in neonates can lead to long term adverse consequences which include physiological effect as well as developmental and behavioral changes.³Several researches reveal that inadequate attention towards pain relief in early life may lead to permanent changes on behaviour and development later.⁴

Received on 22.05.2015 Modified on 24.06.2015

Asian J. Nur. Edu. and Research 5(4): Oct.- Dec.2015; Page 457-460

DOI: 10.5958/2349-2996.2015.00093.2

However the issue of administration of analgesic among newborn babies has been largely neglected in most of the clinical settings because of insufficient knowledge among care giver regarding the long term adverse effect of pain. Various therapeutic and preventive pain management strategies including some of the pharmacological and non pharmacological interventions are reported to be effective in reducing neonatal and infant pain. Judicious assessment of pain perception and application of appropriate interventions on the part of the care givers would produce the best result.⁵

Studies shows that newborns do not receive appropriate intervention for pain management i.e. they are under medicated. If at all they are medicated, then only for painful invasive procedure. So it requires a prime attention and basic need to identify the effective pain intervention for the newborn. So that nurses can effectively and easily implement as an independent practitioner and educate he health care providers on this subject.⁶Taking in to account the adverse effect of pain medication, non pharmacological method is preferred to manage pain if possible which would be simple, acceptable and well tolerated by the newborn.⁷Studies support that sucrose and pain relief are interrelated because sucrose works by stimulating endogenous opoid in the newborn’s brain which provides analgesia naturally.⁸ Administering 0.5to1 ml of 24% oral sucrose just two minutes before procedure can reduce their response to pain and shortens time it takes to stimulate sympathetic nervous system. In a met analysis it is reported that 24% of sucrose given 2 minutes prior to invasive procedure where effective for neonatal providing analgesia for 5-7 minutes.⁹

Due to lack of time and knowledge, and due to the adverse effect of pharmacological therapy for pain management, appropriate interventions are not taken to manage the procedural pain in most of the clinical settings in all over India. Oral sucrose administration is a very simple and cost effective strategy for relieving pain during venipuncture there by reducing the long term adverse consequences and relieves parental stress which gave an insight to the investigator to conduct the present study.

OBJECTIVE:

· To evaluate the effectiveness of pre-procedure administration of 24% oral sucrose in reduction of pain during venipuncture among neonates admitted in NICU.

· To find out the association between pre intervention pain score with selected socio demographic variables.

MATERIAL AND METHODS:

A quasi experimental research design was adopted to evaluate the effectiveness of pre procedure administration of 24% oral sucrose during venipuncture in neonates. The present study was carried out in Neonatal Intensive Care Unit (NICU) of IMS and SUM Hospital, Bhubaneswar over a period of 2 months. The tool for the present study was prepared after reviewing of literature related to various pain assessment scales and validated by experts. The tool consists of the baseline Performa for demographic variable and NIPS (Neonatal Infant Pain Scale) a validated behavioral acute pain scale for pain assessment. The scale measures the behavioral responses of the neonatal and infants. It is composed of six indicators i.e. facial expression, cry, breathing pattern, arm and leg movement and state of arousal. Each behavioral indicator is scored with 0 or 1 except for cry, which is scored with 0, 1, 2. Neonates are observed for one minute before during and after the procedure to assess completely each indicator and a numeric score are assigned to each. Total pain score ranges from 0 to 7. According to NIPS 0-2 score indicates mild pain, 3-4 indicates moderate pain and 5-7 indicates severe pain. 30 neonates meeting the inclusion criteria were selected as samples by purposive sampling technique. Newborn babies who were hemodynamic ally unstable, already receiving analgesia and sedation, intubated and unconscious were excluded from the study. After seeking written permission from the medical superintendent of IMS and SUM Hospital, Bhubaneswar and ethical clearance from the ethical committee data collection was started. Informed consent was taken from their parents.

During the first venipuncture pain score was assessed with routine care and this was taken as control group. When the same neonates were undergoing venipuncture for the second time pain score was assessed after administration of 0.5 ml and 1 ml of 24% sucrose to 28-34 weeks and 35-40 weeks gestation babies respectively through disposable syringe over the tongue just 2 minutes before the venipuncture. Data was analyzed using both descriptive and inferential statistics.

RESULTS:

Table 1 Socio demographic variables of the study subjects.

VARIABLE

n (%)

Gestational age:

28-34 weeks

35-40 weeks

17 (56.7%)

13 (43.3%)

Gender

Male

Female

17 (56.7%)

13 (43.3%)

Weight

1000-1499 gm

1500-2499 gm

> =2500 gm

7 (23.3%)

11 (36.7%)

12 (40%)

Table 1 depicts majority of the study subject belongs to the gestational age category 28-34 weeks, i.e. 17 (56.7%), 35-40 weeks gestation were 13 (43.3%) with respect to gender male babies were 17 (56.7%) and females were 13 (43.3%). Majority of 12 (40%) babies weight were >= 2500 gm, 11(36.7%) babies had weight between 1500-2499 gm and 7(23.5%) babies had between 1000-1499 gm.

Table 2 shows the mean pain score as per NIPS in both control and experimental group. In control group, the mean ± SD pain score was 5.2 ± 1.261 where as in experimental group it was 2.9 ± 0.937 with mean difference of 2.3. There was significant reduction in the mean pain score during venipuncture performed after administration of 24% oral sucrose solution (p<0.0001).

Figure 1 Pain categories as per Neonatal Infant Pain Scale among neonates in experimental and control group.

Figure 1 shows categorization of pain into mild, moderate and severe pain as per NIPS. In control group 22 (73.4%) subjects experienced severe pain where as only 2 (6.7%) subjects experienced severe pain in the experimental group.

Table 3 shows, the mean pain score of various parameters as per NIPS in both control and experimental group. In control the mean ± SD pain score for facial expression, cry, breathing pattern, Arm movement, leg movement, state of arousal were 0.8±0.040, 1.36±0.61, 0.5±0.50, 0.9±0.30, 0.73±0.44, 0.86±0.34 respectively where as in experimental group it was 0.53±0.5, 0.76±0.56, 0.23±0.43, 0.5±0.58, 0.46±0.50, 0.36±0.49 respectively. There was significant reduction in the mean pain score during venipuncture performed after sucrose solution administrate.

Table 3 Area wise mean pain score on various parameters of NIPS.

ITEM	Control Group		Experimental Group		Paired t test	Df	p value
ITEM	Mean	SD	Mean	SD	Paired t test	Df	p value
Facial Expression	0.8	0.40	0.53	0.50	3.24	29	0.003 Very statistically significant
Cry	1.36	0.61	0.76	0.56	4.03	29	0.0004 Extremely statistically significant
Breathing Pattern	0.5	0.50	0.23	0.43	2.8	29	0.009 Very statistically significant
Arm movement	0.9	0.305	0.5	0.50	3.88	29	0.0006 Extremely statistically significant
Leg movement	0.73	0.449	0.46	0.50	2.8	29	0.009 Very statistically significant
State of arousal	0.86	0.34	0.36	0.49	5.38	29	<0.001 Extremely statistically significant

Table 4 Relationship of age with pain score as per neonatal pain score as per neonatal infant pain scale (NIPS) with of set groups.

	Age in Weeks		df, ANOVA F ratio p
	28-34 weeks mean ±SD	35-40 weeks Mean ± SD	df, ANOVA F ratio p
NIPS score in experimental group	2.94±1.028	2.7±0.832	29 0.471 0.491
NIPS score in control group	5.4±1.17	4.8±1.34	29 1.704 0.202
Mean difference, t test, df, p	2.5 0.6703 29 0.0001	2.1 4.92 29 0.0001

Table 4 shows that there is no such relationship between the age and the pain score in the experimental group as well as in the control group as per one way ANOVA (p<0.491) , (p<0.202). There is significant reduction of mean pain score in all the age groups of experimental group when compared with control group using paired t-test (p<0.0001) which indicates that the impact of pre procedure administration of sucrose in reduction of pain is there in all the age groups. No association were observed between pre intervention pain score of neonates with selected demographic variables like age, gender, weight, day of life and method of delivery.

DISCUSSION:

Pain management among neonates has become a major concern in recent years due to its long term adverse effect. More emphasis and attention has been given to a variety of pre procedure pain management strategies especially various non pharmacological methods. In present study 24% oral sucrose administration before an acute painful procedure is effective in managing painful procedure as evident by decreasing behavioral pain indicator and composite pain score as measured by NIPS which is supported in a similar study by Anna Taddio et.al. (2008),¹⁰ where they have reported that mean pain score was lower among newborn who received sucrose than the babies those received placebo. Fathia A Elserafy et.al (2009) conducted a double blind randomized control trial on 24 % oral sucrose and pacifier for pain relief during simple procedure in pre term stated that the combination of pacifier and sucrose 24 % solution showed statistically and clinically effect.¹⁰ Similar results were described in previous studies conducted by Stevens B., Yamada J (2004), Curtis S J (2007) where sucrose was found to be effective and safe in acute procedural pain management.^11,
12,13The result of the present study revealed that there is a significant reduction in pain during venipuncture in the experimental group than the control group .Administration of 24 % sucrose solution is effective in reduction of pain among neonates. Administration of Sucrose can be applied in nursing practice of pain management in various paediatric settings as it can reduce pain during simple presentation. Similar studies can be conducted to compare the effect of sucrose with other non pharmacological pain management strategy.

LIMITATION:

· The study was confined to small group. This limits the generalization of the finding only to the study sample.

· The tool used in the present study measures only behavioral parameters on pain perception among neonate.

RECOMMENDATION:

Other studies can be conducted to find out the effect of sucrose along with other non pharmacological method during other invasive procedure. Similar study can be replicated on large sample to generalize the study finding.

CONCLUSION:

Sucrose is a simple and cost effective pain management strategy to reduce the acute pain so it should be used as and when required in all the clinical settings.

REFERENCE:

1) Young K D. Paediatric procedure pain. Annals of Emergency Medicine. 45(2);2005:160-171.

2) International Association for the study of pain. Pain taxonomy. IASP. 2011

3) Gibbins S, Stevens B. State of the art: Pain assessment and management in high risk infant. Newborn and infant nursing reviewed. 1(2); 2001: 85-96.

4) Anand K, Scalzo F. Can adverse neonatal experiences alter brain development and subsequent behaviour. Biology of the neonate. 77; 2000: 69-82.

5) American Academy of Paediatric Committee on psychological aspect of child and family health and American pain society task force on pain in infant, children and adolescent. APS Bulletin. September/October 2001:.11:15

6) Breanne Z. Infant Pain Management (Online). Jan 21^st 2012: url: http://digitalcommno.liberty-edu.

7) Abad F, Diaz N, Domeneche E, Robayera M and Rico J. Oral sweet solution reduce pain related behaviour in preterm infants. Acta Pediatrica. 85; 1996: 854-858.

8) Jonhnston C, Frank L, Petryshan P and Jack A. The efficacy of developmentally sensitive intervention and sucrose for relieving proceduresal pain in very low birth neonate. Neuro Res. 98; 1999:9835-43.

9) Steven B, Taddio A, Ohisson A and Einerson T. The efficacy of sucrose for reliving procedural pain in neonates: a systematic review and metanalysis. Acta Paediatric. 86; 1997: 837.

10) Taddio A and Shah V. Effectiveness of sucrose analgesia in newborn undergoing painful medical procedure. Canadian Medical Association Journal. 179(1); 2008: 37-43.

11) Fathia A. Elserafy and Saad A. Oral sucrose and a pacifier for pain relief during simple procedures in preterm infant a randomized control trial. Annal of Saudi Medicine. 29(3); 2009: 184-188.

12) Stevens B, Yamada J and Ohisson A. Sucrose for analgesia in newborn infant undergoing painful procedure. Cochrane database systematic review. 2004.

13) Curtis S J, A Jou H, Aiis and Vandermeer B. A randomized controlled trial of sucrose and /or pacifier as analgesia for infant receiving venipuncture in a pediatric emergency department. BMC Pediatric Journal. 18; 2007: 7:27.

Received on 22.05.2015 Modified on 24.06.2015

Asian J. Nur. Edu. and Research 5(4): Oct.- Dec.2015; Page 457-460

DOI: 10.5958/2349-2996.2015.00093.2

ITEM	Control Group		Experimental Group		Mean Diff.	Df, t. value	p value
	Mean	SD	Mean	SD
Total pain score	5.2	1.261	2.9	0.937	2.3	29, t=9.38	<0.0001 Extremely statistically significant