Jamie Villanueva

Georgetown University Georgetown NURO 540 - 705

University
EVIDENCE TABLE AND SUMMARY OF RESULTS DOSE AND ADMINIST
Patient Group Recommended maximum for a particular procedure Recommended maximum in 24 hours <1500 grams 0.2-0.5 mls 2.5 mls Babies 0-1 months 0.2-1ml 5 mls

INTRODUCTION & STATEMENT OF THE PROBLEM

Approximately 7-10% of neonates are born preterm and many full term neonates are admitted into the NICU for surgical and medical management of disease process.

PURPOSE
To explore the efficacy and safety of oral sucrose when used in procedural pain management for preterm, full term neonates and infants. To generate guidelines on the use of oral sucrose for procedural management that are based on best current evidence
REFERENCE

TION
Infants 1-12 months 1-2 mls 5 mls

Altun-Koroglu (2010). Hindmilk for procedural pain in term neonates.

Gibbins (2002). Efficacy and Safety of Sucrose for Procedural Pain Relief in Preterm and Term Neonates. Kassab (2012). Sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age. Lefrak (2006). Sucrose analgesia: identifying potentially better practices. Okan (2007). Analgesia in preterm newborns: the comparative effects of sucrose and glucose. Riddell (2012). Non-pharmacological management of infant and young child procedural pain.

EVIDENCE KEY FINDINGS, OUTCOMES OR RECOMMENDATIONS LEVEL II Significant reductions in crying time, duration of the first cry and tachycardia, time needed for return to baseline heart rate, and the average and 1- and 5-minute NFCS scores in the hindmilk group when compared with the distilled water group.
II I Combination of sucrose and nonnutritive sucking is the most efficient intervention for single heel lances. There is insufficient evidence to confidently judge the effectiveness of sweet-tasting solutions in reducing needle-related pain in infants (one month to 12 months of age) Further well controlled RCTs are needed to determine the optimal concentration, volume, method of administration, and possible adverse effects. Guidelines that included indication, dosage per painful procedure, age-related dosage over 24 hours, method of delivery, and contraindications were developed. Both sucrose and glucose administered orally before a heel prick reduce the pain response in preterm infants. In preterm infants: there was sufficient evidence to recommend oral sucrose for analgesia In neonates: there was sufficient evidence to recommend non-nutritive sucking-related interventions as an efficacious treatment for acute pain reactivity and pain-related regulation. In older infants: there was limited evidence for the effect of nonnutritive sucking on immediate regulation and video-mediated distraction for both pain reactivity and pain-related regulation. Oral sucrose does not significantly affect activity in neonatal brain or spinal cord nociceptive circuits, and therefore might not be an effective analgesic drug. Consistent use of oral sucrose during the first month of life in hospitalized premature infants is safe and effective Sucrose is safe and effective for reducing procedural pain from single events.

The concentration of the sucrose product 24 - 33% does not alter the recommended volume to be administered

SEARCH ST
TECHNOLOGICAL AND MEDICAL ADVANCES IMPROVED OUTCOMES INCREASE PAINFUL PROCEDURES

TEGY & RESULTS

CLINICAL P

CTICE IMPLICATION

With the considerable adverse effects of medications that are used to treat pain especially in the neonates focus has shifted on the utilization of SUCROSE, a safer, more easily acquired and cost effective pain management in this age group.

MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Methodology Register, CINAHL, Joanna Briggs Institute, EBSCOhost Interface, Dynamed and Google Scholar: Search terms: oral sucrose, sweet ease, neonatal pain, pain, pediatric pain, heel lance, venipuncture, pain management, nonpharmacologic, nonnutritive sucking & procedural pain management.

III II I

Other methods of pain relief, including nonnutritive sucking (NNS) and skin-to-skin should be considered in combination with sucrose to reduce or eliminate the pain significantly in this population.

COMPONENTS OF P

CTICE CHANGE

SIGNIFICANCE OF THE PROBLEM

Evidence shows that children who experience moderate pain such as with immunization during infancy have significant long term physiological, psychological and behavioral sequelae: LEVEL II: 5 WELL DESIGNED RANDOMIZED CONTROL TRIALS

Decreased immune system functioning Increased sensitivity to pain Increased avoidance behavior Social hypervigilance Higher levels of anxiety before a painful procedure

LEVEL III: 1 PROTOCOL; 7 SUPPLEMENTAL REFERENCE ARTICLES

Better Pain Management

Slater (2010). Oral sucrose as an analgesic drug for procedural pain in newborn infants: a randomized controlled trial. Stevens (2005). Consistent management of repeated procedural pain with sucrose in preterm neonates: is it effective and safe for repeated use over time? Stevens (2013). Sucrose for analgesia in newborn infants undergoing painful procedures.

II

II I

LEVEL I: 4 SYSTEMATIC REVIEWS

PICOT QUESTION
Preterm and full term neonates in NICU Infants 1 month to 1 year for routine clinic visit, pediatric ward and PICU admission Utilization of oral sucrose commonly knows as sweet ease for pain management Compare the results of the outcomes of standard care with and without the intervention Decreased pain during venipuncture, heel lance or any other pain or discomfort inducing procedures that cause a break in the skin Entire duration of the procedure In hospitalized newborn aged 0 -12 months, is oral sucrose safe and effective when used in procedural pain management?
For questions please email: jv509@georgetown.edu

On-going Evaluation

ROSSWURM AND LA
INCLUSION CRITERIA: MINOR PAINFUL PROCEDURES i.e., heel lance, venipuncture and blood draws. Studies that involves term, preterm neonates and infants less than a year old. CONTROL CONDITIONS: no treatment; distraction; water and breast milk administration and nonnutritive sucking with pacifier OUTCOME MEASURES were the physiological, behavioral or both pain indicators with or without composite pain score i.e. ., Crying time, Neonatal Infant Pain Scale(NIPS), Neonatal Facial Coding System (NFCS) and Premature Infant Pain Profile (PIPP).

BEES MODEL OF CHANGE

4. DESIGN
practice change

RECOMMENDATION FOR P
6. INTEGRATE AND MAINTAIN
change in practice

CTICE CHANGE
ON-GOING EVALUATION

1. ASSESS
need for change in practice
Include stakeholders Collect internal data about current practice Compare internal data with external data Identify problem

2. LINK
problem intervention and outcomes

3. SYNTHESIZE
best evidence

5. IMPLEMENT AND EVALUATE

change in practice
Pilot study demonstration Evaluate process and outcome Decide to adapt, adopt, or reject practice change

CONTINUOUS RESEARCH
Further research needed on determining the minimally effective dose of sucrose; Effect of repeated administration; A standardized and validated assessment tool focusing on long-term neurodevelopmental outcomes should be done at 18-24 months

STAFF EDUCATION

Use standardized classification systems and language Identify potential interventions and activities Select outcomes indicators

Search research literature related to major variables Critique and weigh evidence Synthesize best evidence Assess feasibility, benefits, and risk

Define proposed change Identify needed resources Plan implementation process Define outcomes

Communicate recommended change to stakeholders Present staff inservice education on change in practice Integrate into standards of practice Monitor process and outcomes

In-service, staff meetings, storyboards, skills lab. Keep practice visible and reinforce it with staff Effective knowledge translation strategies are required to translate evidence on sucrose into practice effectively.

Continuous evaluation of current practice and literature available