Introduction
Oral sucrose is a safe and effective mild analgesic which is effective in decreasing short-term pain and distress during minor procedures. Small amounts of sweet solutions (oral sucrose) are placed on the infant's tongue to reduce procedural pain. Breastfeeding (providing comfort, diversion and maternal
contact) should be used where available to relieve procedural pain. The application of supportive measures such as; kangaroo care, facilitated tucking, swaddling, warmth, NNS and distraction (in older infants), should occur prior to oral sucrose administration. Oral sucrose administration is clinically
indicated for the reduction of procedural pain and distress in infants 0-18 months at RCH.
Aim
To provide information for the safe and effective administration of oral sucrose to neonates and infants, prior to painful procedures. Supporting optimal procedural pain management, oral sucrose is to be administered with supportive interventions outlined in this guideline. Staff administering oral
sucrose must follow the recommendations for patient groups, identify risks and complications.
Definition of Terms
- Oral sucrose for procedural pain management is a sweet solution which reduces pain in neonates and infants. By providing taste stimulation to the cellular membrane receptors in the brain, in which the endogenous opioid system is located, the sweet solution may be effective in
pain reduction.
- Pain is a subjective experience as described in the formal definition: "An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage" (
www.iasp-pain.org). Note: The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment.
- Kangaroo Care refers to a neonate lying on the bare skin of their mother or father, upright at a 40-60 degree angle and covered by parent’s shirt/ gown with an additional blanket as required.
- Facilitated Tuckingrefers to holding a neonate’s body so that the limbs are in close proximity to the trunk. The neonate is held side-lying in a flexed position, this technique involves touch and positioning, and promotes a sense of control for the
neonate.
- Non-Nutritional Sucking (NNS) refers to use of a dummy to promote sucking without breast milk or infant formula.
- EBM Expressed breast milk
Assessment
Indications
Oral sucrose is a mild analgesic and should only be used clinically for the reduction of pain during minor procedures. The mechanism is an orally mediated increase in endogenous opioid. The analgesic effect lasts 5-8 minutes making it an ideal strategy for the management of short term pain.
Oral sucrose is most effective for preterm and term neonates (less than 28 days old) and benefits are demonstrated in older infants with an increased dose. The evidence and efficacy of using oral sucrose in the term neonate to 12 months of age has been demonstrated. Patient groups such as neonates
< 32 weeks and
infants > 12 months require further investigation. Evidence suggests that oral sucrose given to Infants > 12 months may continue provide some analgesia and a calming effect. Oral sucrose is recommended at RCH to infants up to 18 months of age as it has been reported to have some analgesic and
calming effects up to 18 months of life. Assessment of the effectiveness of oral sucrose using an appropriate RCH pain assessment tool is also recommended.
RCH Nursing Guideline:
neonatal pain assessment.
Procedures which are known to cause pain and/ or distress in infants may include:
- Blood tests - heel pricks, venepuncture or arterial stab
- IVC & line insertion
- Lumbar puncture
- Dressings - wound/ stoma / removal of adhesive tape & sutures
- Treatment of IV extravasation, excoriated or broken skin
- IDC & NGT insertion
- IM, SC injection/ Insuflon
- Eye examination
- Insertion of NPT / tracheostomy care
- Bowel washout
- Attachment & removal of EEG / ECHO
- Endotracheal (ETT) restrap* (
use NBM dosing)
Oral sucrose may be considered as an adjunct to strong analgesic and topical local anaesthetic during invasive or distressing procedures such as chest drain insertion, laser therapy, ROP examination and circumcision.
Oral sucrose is not appropriate for the management of continuing pain or distress. It may be used as a bridge for infants in distress to be examined and to assess the cause of inconsolability. However, support measures should precede oral sucrose administration.
Contraindications
- Sucrose intolerance - Sucrase-isomaltase deficiency (CSID)
- Fructose intolerance
- Glucose-galactose malabsorption
- Muscle relaxed neonates and infants
Caution - Infants at Risk
- Premature infants - oral sucrose administration is supported using very low doses.
- Neonates and infants with suspected
Necrotising Enterocolitis, un-repaired Trache-oesophageal Fistula, nil
orally status, altered gag or swallow reflex should have medical approval before oral sucrose is ordered. With medical approval these infants may have the nil by mouth (NBM) dose of oral sucrose applied with a small swab directly onto the tongue.
- Neonates and infants with Hypoglycaemia or
Hyperglycaemia also require medical approval for oral sucrose to be used for procedural pain. Research supports that sucrose given orally, for procedural pain management within the recommended dosing, does not alter Blood Sugar Levels (BSL). Note: Hypoglycaemic infants may have a standing order for 66%
oral sucrose to treat low BSL, ensure both orders are clear in their intent and medically approved.
- Endotracheal (ETT) restrap - the NBM dose of oral sucrose may be applied directly onto the infants tongue using a mouth swab
Management
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.
There is no analgesic effect if sucrose is given directly into the stomach via a nasogastric tube. Oral sucrose is more effective if given with a dummy as this promotes Non-Nutritional Sucking (NNS) which contributes to calming.
How to give oral sucrose
- Check for contraindications or risk requiring medical consult
- Prepare the infant for the procedure using
supportive measures
- Prepare the amount of oral sucrose – see
dosing
- The dose is to be given orally on to the anterior of the tongue
- Give 1/4 or less (of the total amount) of oral sucrose 2 minutes prior to the start of the procedure
- Offer a dummy if this is a normal part of the infant’s care
- Give a small amount at the start and incrementally throughout the procedure
- Analgesic effect may last 5-8 minutes from first administration, observe and dose to effect
- Follow the recommended dosing for the patient and discard the oral sucrose syringe post administration
- Consult the medical team if the oral sucrose is ineffective or if the recommended amount is reached, rest the patient and reassess the pain management plan
Be
sweet to babies video
Procedural
Pain Management
Dosing
| 33% Oral Sucrose Administration
(RCH pink solution) |
|
Patient Group
(corrected Age) |
< 32 weeks & NBM |
≥ 32 Weeks to term |
Infants
0-1 month |
Infants
1-18 month |
|
Suggested Incremental doses
Single event
Maximum dose |
0.1 mL
0.2 mL |
0.1 mL
0.2-0.5 mL |
0.1 mL
0.2- 1 mL |
0.25-0.5 mL
1-2 mL |
|
Suggested 24 hour
Maximum dose |
1 mL |
2.5 mL |
5 mL |
5 mL
10 mL in > 3 months |
- RCH Pharmacy supplies oral sucrose 33%, which is a refrigerated product
- Pre-packaged oral sucrose is available without refrigeration
- The concentration of the oral sucrose product 24% or 33% does not alter dosing. However, dosing of the pre-packaged solutions will be based on drops (see product information for millilitres to drops conversion)
- Recommended dosing volumes are based on an inpatient infant requiring no more than five painful procedures / day, unless critically ill and receiving appropriate strong analgesia. There is no evidence to provide the exact dose or the maximum amount to be given in a 24 hour period. Research supports small volumes, dose to effect and repeat only as required.
- If an infant requires more than the recommended maximum in 24 hours discuss with the nursing and medical team re: additional oral sucrose or alternative pain management options.
- NBM dosing requires application of oral sucrose to the infant’s tongue using a mouth swab.
- When using a swab to deliver sucrose, ensure that the dose is measured out prior syringing on to swab.
Supportive Measures
As the oral sucrose effects are short term (5-8 minutes) procedural pain management requires additional supportive measures:
- Prepare and position the infant PRIOR to the procedure - ideally warm, calm and parental contact.
- Avoid over stimulation before and after the procedure, reduce environmental stressors such as noxious stimuli e.g. Noise, lighting and excessive handling.
- Avoid interruptions once commencing the procedure; remain with infant throughout the oral sucrose administration - ideally two staff for all procedures and consider parental role.
- Breastfeeding and skin to skin where available is preferable – the sweet taste of breast milk has an analgesic effect and parental contact provides comfort.
- Although EBM is not as effective at reducing pain when compared to sucrose or breastfeeding, it can be considered as an alternative.
- NNS - dummy/pacifier may be used only when known to be a normal part of the infant's care and when the infant is able to suck.
- Full or partial swaddling, holding, cuddling, nesting, facilitated tucking and kangaroo care is recommended. Providing support, containment and minimising limb flailing, comforts the infant and allows the parent to have an active role.
- Neonates are best supported with developmentally appropriate positioning; knees flexed, arms close to the body and hands to mouth.
- Infants >6 months (or once sitting) are best supported in an upright position. This provides the infant with a greater sense of control. Distraction e.g. sight/sound toys, bubbles or singing is appropriate to minimise distress in older infants.
Documentation
Oral sucrose administration requires documentation to prevent exceeding the maximum recommended dose in 24 hours. The following staff: Nursing, Medical, Allied Health, Technicians and Pathologists may order sucrose at RCH. Documentation of pain scores prior to and following administration of oral sucrose is recommended to evaluate effectiveness.
Requirement
- Check previous dosing on the MAR to ensure recommended maximum 24 hour dosing is not exceeded. (See: oral sucrose dosing table)
- Document oral sucrose percentage (RCH supplied 33%), patient group e.g. 0-1 month, dose given and the indication (procedure)
Outpatient
- Oral sucrose administration may be documented as a nurse initiated medication
- RN’s and Medical staff document oral sucrose administration on the MAR as a PRN medication
- Allied Health, Technicians and Pathology Collectors document oral sucrose administration with a RN if available. If an RN is not available oral sucrose administration is documented on the outpatient request slip which is then scanned into the EMR
Inpatient
- Oral sucrose administration may be documented as a nurse initiated medication
- RN’s and Medical staff document oral sucrose administration on the MAR in the PRN section.
Storage and Availability
There is no evidence to suggest that oral sucrose from a sealed bottle, stored in a temperature regulated refrigerator leads to bacterial growth. The oral sucrose dose should be administered as recommended and the syringe discarded immediately. For areas without refrigeration order the pre-packaged solutions.
RCH bottled oral sucrose is obtained from the RCH Pharmacy and stored in the refrigerator (which must be temperature regulated and monitored). RCH oral sucrose has a one month expiry date.
Pre-packaged sucrose at RCH - is stored at room temperature with expiry as per manufacturer. To order pre-packaged sucrose please contact stores.
Special considerations
There is no evidence to show that oral sucrose used for procedural pain management affects future teeth development or that it has any long-term adverse effects. However, dose recommendations and maximum volumes should be strictly adhered to.
Family Cantered Care
- RCH staff administering oral sucrose for procedural pain management are required to ensure that parents understand the rationale for this intervention.
- RCH staff are advised to follow the recommendations of providing supportive measures and breastfeeding, which supports parental contact and inclusion.
- RCH staff are to advise parents that oral sucrose is not appropriate for comforting infants and that it is not recommended for use at home.
Companion Documents
Links
Evidence Table
Sucrose (oral) for procedural pain management in neonates and infants evidence table.
Please remember to
read the disclaimer
The development of this nursing guideline was coordinated by Alison Kendrick, Clinical Nurse Educator, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated February 2021.
