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Nursing guidelines

Sucrose (oral) for procedural pain management in infants



  • Introduction

    Oral sucrose is a safe and effective mild analgesic which is used for 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. The proposed analgesic action is a sweet-taste mediated opiate response.

    Breastfeeding or skin to skin care (also known as kangaroo care) should be used when possible and feasible to relieve procedural pain. The application of additional supportive measures such as facilitated tucking, swaddling, warmth, non-nutritive sucking and distraction (in older infants), should also occur prior to oral sucrose administration and throughout the procedure. 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. Clinicians administering oral sucrose should follow the recommendations for patient groups, identify risks and complications.

    Definition of Terms 

    • Facilitated Tucking: refers 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. Can be used with oral sucrose, or small volumes of breast milk or infant formula. Note: small volumes of breastmilk and infant formula are less sweet and therefore less effective for pain management than sucrose solutions
    • 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 needs appropriate pain-relieving treatment. 
    • Procedural Holding: is also referred to as “positioning for comfort”.  Infants above 3 months may benefit from being positioned upright in close proximity to a parent or carer, where possible.
    • Skin to skin Care (Kangaroo Care) refers to a neonate lying on the bare skin of their mother or father or other family friend upright at a 40–60-degree angle and covered by parent’s shirt/ gown with an additional blanket as required. 
    • Swaddling- Securely wrapped in a blanket/ similar cloth to restrict movement.

    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 around 5-8 minutes in newborns, and a shorter time (around 1-3 minutes) in infants beyond the newborn period, 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) although 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 < 24 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.

    Oral sucrose may be considered as an adjunct to stronger analgesia and topical local anaesthesia during invasive or distressing procedures such as chest drain insertion, laser therapy, ROP examination.

    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. 

    Procedures which are known to cause pain and/ or distress in infants, where the use of sucrose should be considered may include:

    • Blood tests - heel pricks, venipuncture or arterial stab
    • IV Cannula & line insertion
    • Dressings
    • CVAD 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* (see NBM dosing below)

    Contraindications 

    • Sucrose intolerance - Sucrase-isomaltase deficiency (CSID)
    • Fructose intolerance
    • Glucose-galactose malabsorption
    • Muscle relaxed neonates and infants

    Neonates and infants requiring caution with sucrose administration 

    The following neonates and infants should have medical approval before oral sucrose is ordered and administered.

    With medical approval, infants with the following conditions, may have a ‘nil by mouth (NBM) dose’ of oral sucrose. This is administered/applied via a small swab directly onto the tongue.

    • Suspected Enterocolitis
    • Un-repaired Oesophageal Fistula
    • Patients with nil orally status
    • Patients under ongoing close monitoring by surgical team, particularly with high gastric loses, or an altered gag or swallow reflex.

    Oral sucrose administration is supported for premature infants using very low doses.

    For ventilated patients undergoing endotracheal (ETT) restrapping procedure, the NBM dose of oral sucrose may be applied directly onto the infant’s tongue using a mouth swab.

    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 indication for both orders are clear in their intent and medically approved. 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.

    Assessment

    Please see the following guidelines for more information regarding pain assessment in Neonates and infants.

    RCH Nursing Guideline: Neonatal Pain Assessment.

    RCH Nursing Guideline: Pain Assessment and Measurement 

    Management 

    Administration 

    All Nursing, Medical, approved Allied Health Staff, Technicians and Pathologists may administer oral sucrose. If the infant is an inpatient and the procedure is necessary, discuss with the bedside nurse if oral sucrose is appropriate and who will be available to observe and support the infant throughout the procedure. Consultation with nursing and/or medical staff in areas such as NICU and PICU is essential due to the population of premature and critically ill infants.

    Things to consider prior to administration

    Breastfeeding or skin to skin care (also known as kangaroo care) should be used when possible and feasible to relieve procedural pain. The slightly sweet taste of breast milk along with sucking and skin to skin contact have analgesic effects.

    Oral sucrose is more effective if given with a dummy as this promotes Non-Nutritional Sucking (NNS) which contributes to calming.

    There is no analgesic effect if sucrose is given directly into the stomach via a nasogastric tube.

    How to administer oral sucrose

    • Check for contraindications or risk requiring medical consultation.  
    • Prepare the infant for the procedure using supportive measures.
    • Prepare the amount of oral sucrose – see dosing below.
    • The dose is to be given orally on to the anterior of the tongue.
      • NBM dosing requires application of oral sucrose to the infant’s tongue using a mouth swab. See photo below. 
      • When using a swab to deliver sucrose, ensure that the dose is measured out prior syringing on to swab. 
    • Give quarter or less (of the total amount) of oral sucrose around 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 as required.
    • Analgesic effect may last 5-8 minutes from first administration, observe infant 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.
    • Ensure every sucrose dose is documented- see documentation.

    Sucrose NBM dosing

    Photo shows how to administer a NBM dose of sucrose. Photo curtsey of RCH Butterfly team.

    Be sweet to babies video

    Available Products

    • 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).

    Dosing

    • 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 maximumin 24 hours discuss with the nursing and medical team re: additional oral sucrose or alternative pain management options.
    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

    Table Created by Nursing Staff at RCH

    Breastfeeding

    • Breastfeeding during a painful procedure refers to the infant latching on the breast and sucking during the procedure.
    • Where possible and feasible, breastfeeding and skin to skin during the procedure is preferable– the slightly sweet taste of breast milk with sucking, and the skin-to-skin contact have analgesic effects.
    • Although EBM is not as effective at reducing pain when compared to sucrose or breastfeeding, it can be considered as an alternative.

    Procedure Considerations and Supportive Measures 

    It is important to consider the necessity of the procedure, and the least painful alternative should be considered if appropriate. Where possible, the procedure timing should take into consideration the infant rest times, planned cares and other interventions.

    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.
    • 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.

    See RCH Nursing Guideline: Procedural Pain Management Clinical Guideline.

    If the infant is displaying signs of being overwhelmed or not coping (such as increased pain scores), then the procedure should be paused so the infant is able to reset.  Two unsuccessful attempts at some procedures, such as venipuncture, would be a typical example of a point of when to consider a different approach or different support measures for the infant.  If the procedure is urgent, then other analgesics options should be discussed, and a supportive procedural plan made.

    Documentation

    Oral sucrose administration is documented in the MAR as per the Medication management procedure. The aim will be to prevent exceeding the maximum recommended dose in 24 hours and to ensure that it is only administered for the purpose of procedural pain support.

    The following staff: Nursing, Medical, approved 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.

    • 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)
    • 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.
    • In an outpatient setting approved 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.

    Storage and Availability

    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.  The oral sucrose dose should be administered as recommended, and the syringe discarded immediately. 

    For areas without refrigeration, order the pre-packaged solutions. Pre-packaged sucrose at RCH is to be stored at room temperature with expiry as per manufacturer. To order pre-packaged sucrose please contact stores.

    Family Centered Care

    • RCH staff administering oral sucrose for procedural pain management are required to ensure that parents and caregivers understand the rationale for this intervention.
    • RCH staff are advised to follow the recommendations of providing supportive measures and breastfeeding/ skin-to-skin care, which supports parental and caregiver contact and inclusion.
    • RCH staff can encourage parents and caregivers, where appropriate, to provide supportive measures such as containment and wrapping when breastfeeding or skin-to-skin care for a procedure is not possible.
    • RCH staff are to advise parents that oral sucrose is not appropriate for comforting infants other than for procedural pain in a hospital environment.
    • RCH staff can educate families that 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. If concerns are raised.

    Companion Documents

    Links


    Evidence Table 

    Reference   Source of Evidence Key findings and considerations
    Banga. S, Datta. V, Rehan. H.S and Bhakhri. Effect of sucrose analgesia, for repeated painful procedures, on short-term neurobehavioural outcome of preterm neonates: a randomized controlled trial. 2016. Journal of tropical pediatrics, 62, 101-106 RCT
    • 93 newborns analysed in a blind randomized controlled trial to receive either sucrose or distilled water for every potentially painful procedure during the first 7 days of enrolment. Study used the Neurobehavioral assessment of preterm infant’s scale at 40 weeks postconceptional age to determine neurodevelopmental status. 
    • There was no statistical difference of neurobehavioral outcome observed between the sucrose and water groups.  
      Benoit B, Martin-Misener R, Latimer M, Campbell-Yeo M. Breast-Feeding Analgesia in Infants. J Perinat Neonatal Nurs. 2017;31(2):145-159. doi:10.1097/JPN.0000000000000253 Systemic review 
      • Review of current evidence relating to the effectiveness of breastfeeding and expressed breast milk feeding in reducing procedural pain in preterm and term infants. 21 eligible studies.
      • Direct breastfeeding found to be more effective than maternal holding, skin to skin, topical anesthetics, music therapy.
      • Breastfeeding more effective than sweet tasting solutions in full term infants. However, both breastfeeding and sweet solution interventions were found to significantly reduce duration of cry and latency of onset of cry compared with placebo.
      • Based on current evidence, expressed breast milk alone should not be considered and adequate intervention.  
      Beuno, M.,Yamada, J., Harrison, D., Khan, S., Ohlsson, A.,Adams-Webber, T., Beyene, J., and Stevens, B. (2013). A systematic review and meta-analyses of non-sucrose sweet solutions for pain relief in neonates. Pain Research Management, 18(3), 151-163.
      		 Systemic Review

      Systematic review and meta-analyses of thirty-eight studies (3785 neonates) Glucose was investigated in 35 trials, with doses ranging from 0.2 mL to 2 mL of 5% to 50% solutions. Other solutions studied were artificial sweeteners, fructose, glycine, honey and maltitol.

      Efficacy and safety of sweet-tasting solutions other than sucrose during acute procedural pain in neonates:

      • Glucose reduces pain scores and crying during single heel lance and venipuncture.
      • 20% to 30% glucose solutions have analgesic effect and can be an alternative to sucrose for procedural pain reduction in healthy term and preterm neonates undergoing a single heel lance and venipuncture.

      Further investigation to establish the efficacy and safety of non-sucrose solutions:

      • Current research demonstrates considerable variability in outcome measurements, due to the volumes and concentrations of non-sucrose solutions administered.
      No studies measured the effects of repeated doses of glucose for procedural pain.  

      Campbell-Yeo. M, Johnston.C, Disher. T, Caddell. K, Vincer.M, Walker.C-D, Latimer.M, Steiner.D.L and Inglis.D. Sustained efficacy of kangaroo care for repeated painful procedures over neonatal intensive care unit hospitalization: a single-blind randomized controlled trial. 2019, 160: 2580-2258. RCT 
      • Stable preterm infants were randomized to receive kangaroo care and water, kangaroo care and 24% sucrose or 24% sucrose before routine procedures throughout their NICU stay. 
      • Premature infant pain profile scores were assessed at 30, 60 or 90 seconds. Maternal kangaroo care seems to remain efficacious as a pain-relieving intervention for infants delivered between 27 and 36 weeks of GA and seems to have comparative efficacy to kangaroo care plus sucrose or sucrose alone.  
        Chang. J, Filoteo. L and Nasr. A.S. Comparing the analgesic effects of 4 nonpharmacologic interventions on term newborns undergoing heel lance- A randomized controlled trial, 2020, J Perinat Neonat Nurs, vol 34 (4), 338-345.  RCT  Randomized trial compared the analgesic effect of 4 nonpharmacologic interventions (breastfeeding, oral sucrose, nonnutritive sucking and skin to skin contact) on term newborns between 24 and 48 hours who underwent a heel lance. All of these interventions are clinically applicable and acceptable when caring for a newborn during a minor painful procedure. 


        Committee on fetus and newborn and section on anesthesiology and pain medicine. Prevention and management of procedural pain in the neonate: An update. 2016. American academy of pediatrics, Pediatric vol 137, 2. Review 
        • A meta-analysis of 57 studies including >4730 infants 25-44 weeks GA concluded that sucrose is safe and effective for reducing procedural pain from a single event.
        • Sucking-related/ swaddling/ facilitated tucking interventions beneficial for preterm infants.
        • Sucking-related, rocking, holding interventions beneficial for term infants.  

           

          Harrison, D., Yamada, J., Adams-Webber, T., Ohlsson, A., Beyene, J., Stevens, B. Sweet tasting solutions for reduction of needle related procedural pain in children aged one to 16 years. Cochrane Database of Systematic Reviews, 2015, Issue 5. Art. No.: CD008408.DOI:10.1002/14651858.CD008408.pub3.

          		 Systemic Review 

          Systematic review of RCT’s, 7 Published and 1 unpublished, in which children aged one year to 16 years, received a sweet tasting solution or substance for needle-related procedural pain.

          Efficacy of sweet tasting solutions or substances for reducing needle-related procedural pain in children beyond one year of age:

          • The evidence is insufficient and conflicting in determining the analgesic effects of sweet tasting solutions or substances during acutely painful procedures in young children (one to four years of age)
          • There is no evidence of analgesic effects of sweet taste in school-aged children.  
           

          Harrison D. Pain management for infants – Myths, misconceptions, barriers; knowledge and knowledge gaps. J Neonatal Nurs. 2021;27(5):313-316. doi:10.1016/j.jnn.2020.12.004

          		  
          • Oral sucrose, when administered to both healthy and sick hospitalised infants, in small volumes, prior to acute painful procedures is a safe, effective, economic, and feasible pain reduction strategy.
          • Recognised myths and misconceptions in previous article. There is no evidence of increased risk of necrotising enterocolitis, dental caries, bacterial overgrowth or hyperglycemia associated with oral sucrose
          • Sucrose used for pain management is endorsed by the Baby Friendly Health Initiative (BFHI)
          • Ongoing studies continue to report inconsistent use of this effective, simple, safe, cost-effective evidence based pain management strategy.
          Hoarau.K, Payet.M.L, Zamidio.L, Bonsante.F, Iacobeli.S, 2021, “Holding-Cuddling” and sucrose for pain relief during venipuncture in newborn infants: a randomized controlled trial. Frontiers in Pediatrics.
          		  RCT
          • 78 infants were equally randomized to receive 24% oral sucrose with non-nutritive sucking (control) or 24% oral sucrose with non-nutritive sucking plus “holding-Cuddling”
          • “Holding-Cuddling” did not significantly reduce pain scores at 30 or 60 seconds, but the rate of infants experiencing high pain scores at 60s after the venipuncture was significantly lower in the experimental group.
          Lago. P, Cavicchiolo. M.E, Mian T, Dalcengio. V, Allegro. A, Daverio.M, Frigo. A.C, Repeating a dose of sucrose for heal prick procedure in preterms is not effective in reducing pain: a randomized controlled trial, Eur J peditri, 2020, 179 (2): 293-301  RCT
          • 72 infants randomized to receive a double dose of sucrose 2 mins prior to a painful procedure.  Repeating a dose of 24% sucrose is not effective at reducing pain during the recovery phase of a skin breaking procedure.
          • Implementation of behavioural strategies in association with sucrose may mitigate pain during this procedure. 
          • Support for “holding-cuddling” held in a secure, cuddling and soothing position 5 minutes prior to the procedure.
             Matsuda, E. (2017) Sucrose as analgesia in neonates undergoing painful procedures, Cochrane Corner, Advanced Journal of Nursing, Vol 117, No 8. Systematic Review
            • Systematic review of 74 RCT’s. 
            • For neonates undergoing venipuncture, composite and multidimensional pain scores and cry variables were reduced by sucrose concentrations of 24% to 30%.
            McNair. C, Campbell-Yeo. M, Johnston. C and Taddio.A, Nonpharmacologic management of pain during common needle puncture procedures in infants, Current research evidence and practical considerations: An Update, 2019, Clin Perinatol 46, 709-730. Systemic Review 
            • It is important to treat needle pain in infants, to reduce distress and suffering and reduce long term negative impact on brain development and functioning. 
            • Swaddling and containment aims to limit the infant’s boundaries, promote self-regulation, and attenuate physiologic and behavioural stress caused by acute pain. 
            • Breastfeeding- systematic review including 21 studies- breastfeeding was more effective than holding, skin to skin and sweet tasting solutions in full term infants
            • Breastmilk- Another review found that breastmilk alone does not seem to be as beneficial as breastfeeding.
            • Pacifier and non-nutritive sucking- systematic review showed sufficient evidence that sucking is efficacious compared to no treatment in reducing pain-related distress in preterm infants and improving immediate pain related regulation in preterm and term infants up to 1 month of age
            • Skin to skin- research suggests a clear role in neonatal pain management
            • Sucrose- administration with a pacifier stimulates non-nutritive sucking, which may improve effectiveness. Onset of action is quick (seconds) but peak at 2 mins and duration of action is up to 10 mins.
             

            Safer Care Victoria Sucrose for procedural Pain in Neonates Updated 2013

            		  National Standard
            • Supported recommended doses of sucrose (nil orally 0.2 ml, <1500g 0.2-0.5mls, 0-1 mth 0.2-1ml, 1-18 mths 1-2 mls
            • 24-33 per cent solutions commonly use
            • Reduction of noxious stimuli and reduction of multisensory stimulation for procedures important. 
            Sawlesshwarkar.K, Singh.M, Bajaj.R, Loya.S, Chiklondhe.R, Bhave.S, Quality Improvement report:  Implementing Use of Sucrose analgesia (non-pharmacological management of neonatal pain) in a standalone private facility level 3 neonatal unit using a point of care quality improvement methodology. (2022) BMJ Open Quality Quality Improvement Project
            • Quality improvement project study using a plan do study act cycle at a level 3 NICU to introduce sucrose for four selected procedures and improve compliance of the change.
            • Pre-education and post education questionnaires were completed by staff, which showed an increase in knowledge from 40% to 80%.
            • Aim to improve compliance of sucrose administration from a current 0% to 80% in 8 weeks.
            • Concerns were addressed during the study, such as the use of pre-filled syringes that were made available at the bedside and staff were involved in finding solutions.
            • Team huddles were also used during the study at points to ensure sustainability.
            • The percentage of babies getting sucrose analgesia was increased to 96.27% and sustained at 80% for 4 years.
            Shah PS, Torgalkar R, Shah VS. Breastfeeding or breast milk for procedural pain in neonates. Cochrane Database Syst Rev. 2023;(8). doi:10.1002/14651858.CD004950.pub4 Systemic Review
            • Updated systemic review including 46 new RCT studies (66 total).
            • Breastfeeding or supplemental breast milk is likely to reduce pain in neonates undergoing painful procedures when compared to no interventions for infants up to 44 weeks gestation.
            • Limited studies of the effectiveness of breast milk in preterm infants.
            • There are different no medication strategies (holding, swaddling, pacifier or sweet solutions) which are used to reduce pain in procedures.
            • Breast milk has not shown same efficacy as breastfeeding.   
            Stevens. B, Yamada. J, Gibbins. S, Harrison. D, Dianne. K, Taddio.A, McNair.C, Willan. A, Ballantyne. M, Widger. K, Sidoni. S, Eastbrooks. C, Synnes. A, Squires. J, Victor. C and Riahi. S. The minimally effective dose of sucrose for procedural pain relief in neonates: a randomized controlled trial, 2018, BMC paediatrics, 18:85
            		Systemic Review 
            • 245 neonates from 4 Canadian tertiary NICUs at 24-42 wks gestation.  Randomised to receive 0.1, 0.5 and 1ml during a heal lance procedure. No difference in pain scores at 30 and 60 secs. 
            • Therefore, concluded that the minimally effective dose for sucrose is 0.1 mL
            • To assess sustained effectiveness, further research is needed.   

            Stevens.B, Yamada.J, Ohlsson.A, Haliburton.S, July 2016, Sucrose for analgesia in newborn infants undergoing painful procedures, Cochrane neonatal group, the Cochrane library.

            		 Systemic Review
            • Systematic review (Cochrane review) looking at 74 studies enrolling 7049 infants.
            • Sucrose has been found to be effective in providing relief for single events procedures, such as heel lance, venipuncture and intramuscular injection in both term and preterm infants.
            • Does not provide effective pain relief for circumcision.
            • Small doses (0.1-0.02g) are efficacious in preterm infants, while larger doses (0.24-0.50g) reduce proportion of crying time for term infants.   
            Sydney Children’s Hospital 
            Pain Management in Newborn infants in the Grace Centre for Newborn Intensive Care- CHW, Practice Guideline, Updated 28 September 2021
            		Clinical Guideline  • Long term consequences of pain are highlighted when neonates are exposed to painful stimuli, such as altered pain processing with increased pain sensitivity, developmental allodynia in preterm babies and reduced subsequent behavioral responses to pain.
            • A lack of behavioral responses does not necessarily indicate a lack of pain.
            • Consideration of least painful method of undertaking of procedure, skilled practitioner
            • Prevention of pain- consider necessity of procedure, non-emergency interventions should be delayed if there are not adequate caregivers to provide support.  

             Yamada.J, Bueno.M, Santos.L, Halibuton.S, Campbell-Yeo, Stevens.B, August 2023, Sucrose for Analgesia (pain relief) in Newborn infants Undergoing heel lance. Cochrane Review. Systematic Review 
            •  Review of 55 studies that included 6273 babies (29 studies had full term babies, 22 had preterm only and 4 had both term and preterm).
            • Sucrose compared to the control treatment probably reduces pain from single heel lances in babies.
            • Evidence uncertain about the effect of sucrose compared to NNS, breastfeeding, laser acupuncture, facilitated tucking.
            • In addition to sucrose, other nonpharmacological approaches to managing procedural pain, such as breastfeeding, skin to skin care and facilitated tucking are recommended for incorporation into routine care whenever possible and sucrose should be used whenever parent-initiated modalities are not possible.
            • Two of the included studies combined the use of sucrose with adjuvant interventions (NNS and containment and sucrose with swaddling), which would contribute to overall pain reduction.
            • More studies are needed to assess the effect of repeated sucrose administration on immediate and long term neurodevelopmental outcomes. 



            Please remember to read the disclaimer


            The revision of this nursing guideline was coordinated by Alison Kendrick, Clinical Nurse Educator, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated August 2024.