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Child health
10.1136/ebnurs-2011-100453
Department of Women’s Health,
Neonatal Service, University
College London Hospital NHS
Trust, London, UK
Correspondence to:
Judith Meek
Department of Women’s Health,
Neonatal Service, University
College London Hospital NHS
Trust, 2nd floor North, 250
Euston Road, London NW1 2PG,
UK; judith.meek@uclh.nhs.uk
84 Evidence-Based Nursing July 2012 | volume 15 | number 3 |
Systematic review
Cochrane review: non-nutritive sucking, kangaroo care
and swaddling/facilitated tucking are observed to reduce
procedural pain in infants and young children
Judith Meek, Angela Huertas
Commentary on: Pillai Riddell RR, Racine NM, Turcotte K, et al. Non-pharmacological management of
infant and young child procedural pain. Cochrane Database Syst Rev 2011;10:CD006275.
Implications for practice and research
■ Kangaroo care, swaddling/facilitated tucking and
non-nutritive suckling are effective techniques for
diminishing responses to procedural pain in preterm
and newborn term infants.
■ The comparative effectiveness of these techniques
against other commonly used methods needs further
analysis.
■ There is insufficient research in the 1-month to
3-year-old age group to make any recommendations.
Different techniques may be appropriate across this
group according to age and disability.
■ Further research using evoked cortical responses is
essential.
Context
Painful procedures are often performed on infants and
young children, and they can have life long consequences,
particularly when repeated frequently and if pain is not
managed effectively. The preverbal population is especially
vulnerable, and we have a responsibility to protect the
fragile developing nervous system. However, it has proved
difficult to extrapolate analgesic techniques from adults to
infants. There have been several reviews of pharmacologi-
cal therapies for procedural pain and this review of non-
pharmacological techniques is thorough and timely.
Methods
Interventions were studied in three age groups. Skin break-
ing and nursing procedures were studied. Circumcision
and ophthalmic examination were excluded as they have
already been reviewed. Contextual, cognitive and behav-
ioural interventions were included, except for breast feed-
ing and sucrose which are the focus of other reviews.
Responses were defined as reactivity (immediate) or
immediate regulation (after 30 s). The outcome measure
was a significant change in pain score, although eight
studies used crying time. This was a comprehensive
search of electronic databases and grey literature. Careful
attempts were made to minimise the risk of bias.
Findings
A total of 3396 participants were analysed from 30 ran-
domised controlled trials (RCTs) and 30 crossover trials with
81 treatment arms. Kangaroo care, non-nutritive sucking
and swaddling were effective for preterm infants for reac-
tivity and immediate regulation. For term infants only non-
nutritive sucking was effective at both times, and rocking
for immediate regulation. There was substantial heteroge-
neity between the studies which needs considering when
interpreting the results. There was insufficient data to anal-
yse the effect of any interventions in the older children.
Commentary
The stimuli considered as noxious included handling for
nappy changes and weighing. Although handling is clearly
stressful for preterm babies, it is not strictly noxious. The
fact that handling elicits behavioural and physiological
responses recognised by pain scoring reflects the difficulty
in differentiating between stress and pain. This is perhaps
a fundamental limitation of using pain scoring scales in
preterm infants. However, there is new evidence that nox-
ious stimulation of preterm infants can elicit generalised
intense delta brush activity rather than localised cortical
responses.1 Therefore the most premature babies may have
a generalised response to all sensory stimulation, albeit
varying in intensity, leading to strong recommendations
for supportive developmental care. The findings of this
study reinforce the evidence for using these techniques.
To date quantitative studies have all used pain scores,
which have further limitations. Although cortical hae-
modymanic responses to heel lance correlate with the facial
component of the PIPP score,2 on a worrying number of
occasions babies in this study mounted a cortical response
without any facial change. This reflects the observation
that stressed infants will tune out and become unrespon-
sive. There is also a long latency to the facial response in
extremely preterm babies,3 which could reduce the total
score, and blur the distinction between the immediate and
the delayed responses measured in the review.
A recent RCT comparing sucrose with water before
heel lances4 demonstrated the expected effect on the PIPP
score but none on the cortical response. Sucrose, and
other behavioural modifiers, may have an effect on phys-
iological stability which is not due to analgesia. The chal-
lenge now is to look at the long-term effects of blunting
behavioural or physiological responses to pain without
necessarily providing analgesia. Will these techniques
reduce the long-term developmental damage caused by
repeated noxious stimulation?
There was insufficient data to draw any conclu-
sions for the 1-month to 36-month group. This is a wide
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Child health

ranging group in terms of cognitive development and so
perhaps it is not surprising that no consistent patterns
emerge. Further studies are required on the different age
bands related to developmental stage and the presence of
developmental delay or sensory impairment.
Competing interests None.
References
1. Fabrizi L, Slater R, Worley A, et al. A shift in sensory processing
that enables the developing human brain to discriminate touch
from pain. Curr Biol 2011;21:1552–8.
2. Slater R, Cantarella A, Franck L, et al. How well do clinical
pain assessment tools reflect pain in infants? PLoS Med
2008;5:e129.
3. Slater R, Cantarella A, Yoxen J, et al. Latency to facial
expression change following noxious stimulation in
infants is dependent on postmenstrual age. Pain
2009;146:177–82.
4. Slater R, Cornelissen L, Fabrizi L, et al. Oral sucrose
as an analgesic drug for procedural pain in newborn
infants: a randomised controlled trial. Lancet 2010;376:
1225–32.

Evidence-Based Nursing July 2012 | volume 15 | number 3 | 85

 Downloaded from http://ebn.bmj.com/ on November 20, 2015 - Published by group.bmj.com

Cochrane review: non-nutritive sucking,

kangaroo care and swaddling/facilitated
tucking are observed to reduce procedural
pain in infants and young children
Judith Meek and Angela Huertas

Evid Based Nurs 2012 15: 84-85 originally published online March 12,
2012
doi: 10.1136/ebnurs-2011-100453

Updated information and services can be found at:

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Topic Articles on similar topics can be found in the following collections

Collections Pain (neurology) (305)
Child health (449)
Infant health (116)
Neonatal health (63)
Infant nutrition (including breastfeeding) (78)
Childhood nutrition (130)
Drugs: musculoskeletal and joint diseases (155)
Pain (palliative care) (79)
Reproductive medicine (328)
Urological surgery (29)

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