Clinical Guidelines (Nursing)

Sucrose (oral) for procedural pain management in infants

  • Introduction

    • Small amounts of sweet solutions (oral sucrose) placed in the infant's mouth reduce procedural pain.
    • The mechanism is an orally mediated increase in endogenous opioid. 
    • The analgesic effects last 5-8 minutes, making it an ideal strategy for management of short term pain. 
    • There is no analgesic effect if sucrose is given directly into the stomach via a nasogastric tube.
    • Sucrose is more effective if given with a dummy as this promotes non-nutritional sucking which contributes to calming2
    • The ongoing use of sucrose in infants with prolonged hospitalisations requiring many doses of sucrose over time for multiple painful procedures has been shown to be safe and effective. 5, 6
    • There is no evidence to show that oral sucrose affects future teeth development3.

    Aim

    This guideline provides information for the safe effective administration of oral sucrose to infants, prior to painful procedures.

    Indications

     Sucrose should only be used as clinically indicated for reduction of procedural pain, and for short term management of distress when other comfort measures have failed.

    Oral sucrose is most effective as a mild analgesic agent for infants in the first month of life2. It has also been shown to have analgesic and calming effects up to 18 months of life. 3

    Target patients are infants up to 18 months undergoing a painful minor procedure.

    Sucrose may be part of the procedural management plan for infants having a range of procedures such as:

    • blood tests by means of heel pricks, venipuncture or arterial stabs
    • intravenous catheter insertion
    • lumbar puncture
    • suture removal
    • dressings
    • urinary catheter insertion
    • intramuscular or subcutaneous injections
    • eye examination
    • adhesive tape removal
    • nasogastric insertion

      Contraindications

    • Infants with known fructose or sucrose intolerance.

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    Important Considerations

    Sucrose is a mild analgesic, effective in decreasing short-term pain during minor procedures.

    Sucrose is only effective when given orally, directly onto the infant's tongue.

    Ensure that pain scores are documented prior to and following administration of sucrose; to evaluate the effectiveness of oral sucrose.

    In addition to sucrose administration the following measures may also help in reducing distress:

    • Breast feeding or non-nutritive sucking using a dummy, if is a normal part of the infant's care, and if the infant is able to suck.
    • Full or partial swaddling  to minimise limb flailing and support containment
    • Reduction in noxious stimuli and over stimulation e.g. noise and lighting
    • Holding and cuddling with a parent or carer
    • Infants >6 months supported upright position as appropriate
    • Distraction for older infants e.g. sight/sound toys, bubbles or singing

    Infants of mothers taking methadone during pregnancy may have altered endogenous opioid systems, resulting in a lack of analgesic effect of oral sucrose in the first days to weeks of life4.  It is important to assess the effectiveness of sucrose in these infants and to use alternative comfort measures until the infants' endogenous opioid system normalises.

    Dose and Administration

    All Nursing, Medical, Allied Health Staff, Technicians and Pathologists may give oral sucrose. If the infant is an inpatient discuss with the bedside nurse if the procedure is necessary, if oral sucrose is appropriate and who will observe and support the infant. Consultation in areas such as NICU and PICU is essential due to the population of premature and critically ill infants.  Sucrose should be used in conjunction with a procedural management plan, rather than an isolated intervention. 

    Only small volumes of sucrose are required. The aim is not to use sucrose inappropriately for ongoing distress. There is no evidence to guide recommended doses or the maximum amount to be given in a 24 hour period2. The recommended maximum amounts are based on an inpatient infant requiring no more than five painful procedures/day, If an inpatient infant requires in excess of the recommended maximum in 24 hours, review the infant's current procedural pain management plan. Discuss with the nursing and medical team whether additional sucrose dosing is appropriate or what alternative management might be implemented.

    Patient group

    Nil Orally

    <1500 grams

    Babies 0-1mths

    Infants 1-18 mths

    Recommended maximum for a particular procedure

    0.2 mls

    0.2-0.5 mls

    0.2-1 ml

    1-2 mls

    Recommended maximum in 24 hrs

    1 ml

    2.5 mls

    5 mls

    5 ml/s

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

    How to give oral sucrose

    • Prepare the total amount of sucrose to be given orally , using an orange oral medication syringe (see table above)
    • Give approximately one quarter of the total amount of sucrose 2 minutes prior to the start of  the procedure
    • Offer a dummy if this is a normal part of the infants care
    • incrementally give the rest of the sucrose throughout the procedure, as needed
    • The analgesic effect lasts 5-8 minutes from first administration
    • Follow recommended amount and consult patient’s medical/ treating team if additional dosing is required
    • Sucrose is not appropriate for the management of continuing pain or distress.

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    Documentation  

    All Nursing & Medical Staff/ Allied Health/ Technicians/ Pathologists may sign for sucrose.

    Inpatient - Record in the as required PRN section of the Medicine Chart (MR690/A) See worked example below.

    Outpatient - Record in a log book or in the patient’s notes (Patient name, DOB, procedure, amount of oral sucrose given)

    Worked example

    Sucrose-worked-example.jpg

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    Storage and Availability

    Bottled sucrose 33% is stored in the fridge for use within one month. Supplied by RCH pharmacy.

    Pre-packaged sucrose products are stored at room temperature and expire after 2 years. To obtain pre packaged sucrose please contact Comfort Kids x7933

    Important links

    Reference List

    1. Harrison D, Johnston L, Loughnan P. Oral sucrose for procedural pain in sick hospitalized infants: A randomized-controlled trial. J Paediatric Child Health 2003;39:591-7.
    2. Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. In: The Cochrane Library, Oxford: Update Software 2004.
    3. Harrison, D.M. Oral Sucrose for pain management in infants: Myths and misconceptions. Journal of Neonatal Nursing 2008, 14, 39-46.
    4. Blass E, Ciaramitaro V. A new look at some old mechanisms in human newborns. Monogr Soc Res Child Dev 1994;59.
    5. Stevens B, Yamada J, Beyene J, Gibbins S, Petryshen P, Stinson J, et al. Consistent management of repeated procedural pain with sucrose in preterm neonates: Is it effective and safe for repeated use over time? Clin J Pain 2005;21:543-8.
    6. Harrison D, Loughnan P, Manias E, Johnston L. The effectiveness of repeated doses of oral sucrose in reducing procedural pain during the course of an infant's prolonged hospitalisation. J Paediatric Child Health 2007;43:A20.
    7. Stevens B, Yamada J, Ohlsson A.  Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane database of systematic reviews, 2010, Issue 1.

    Evidence Table

    Oral Sucrose Evidence Table

     

    Please remember to read the disclaimer

    The development of this clinical guideline was coordinated by Alison Brunt, Clinical Nurse Consultant, CPM Services. Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive Director Nursing Services. Revised September 2012 (First published April 2010)

     

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