Oral sucrose for procedural pain in infants

Abstract

Rebeccah Slater and colleagues1Slater 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: 1225-1232Summary Full Text Full Text PDF PubMed Scopus (228) Google Scholar report that oral sucrose did not diminish localised brain activity (electroencephalography [EEG]) and a spinal nociceptive reflex (electromyography [EMG]) after heel lance. Conversely, sucrose significantly reduced behavioural expressions, consistent with a Cochrane review.2Stevens B Yamada J Ohlsson A Sucrose for analgesia in newborn infants undergoing painful procedures.Cochrane Database Syst Rev. 2010; 1 (CD001069.)PubMed Google Scholar We consider the conclusion, “sucrose should not be used routinely for procedural pain in infants without further investigation”1Slater 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: 1225-1232Summary Full Text Full Text PDF PubMed Scopus (228) Google Scholar unjustified. The selected indices did not recognise pain as engaging widely distributed, serial and parallel, dynamic activation in multiple areas of the brain.3Price DD Psychological and neural mechanisms of the affective dimension of pain.Science. 2000; 288: 1769-1772Crossref PubMed Scopus (1468) Google Scholar, 4Tracey I Imaging pain.Br J Anaesth. 2008; 101: 32-39Crossref PubMed Scopus (186) Google Scholar EEG activity was reported for only one of 32 recording electrodes, and thus did not address multiple brain regions that might have been activated.5Hofbauer RK Rainville P Duncan GH Bushnell MC Cortical representation of the sensory dimension of pain.J Neurophysiol. 2001; 86: 402-411PubMed Google Scholar The suggestion of dissociation between brain activity and the experience and expression of pain is reminiscent of Descartes' dualism. The intervention clearly affected behaviour, with the neural measures not identifying the biological substrate. Other methodological issues could account for differences between the neural and behavioural measures. The single control procedure was not randomly ordered. Only 44 of 59 infants were included in the analysis of EEG and premature infant pain profile (34 of 59 in the EMG analysis). These 25% and 42% attrition rates, respectively, might have eliminated infants with vigorous facial displays contributing to dissociation between measures. Although infant pain assessment is imperfect and imprecise, caution should prevail concerning conclusions on well supported pain-relieving strategies. Because one selected measure of neural activity was not responsive to sucrose does not preclude other measures from being responsive. Researchers and clinicians have an ethical responsibility to consider oral sucrose for painful procedures, while doing further effectiveness research using validated cognitive and behavioural assessment measures. We declare that we have no conflicts of interest. Oral sucrose for procedural pain in infants – Authors' replyGiven the importance of pain and pain relief in clinical practice, the area is extraordinarily poorly understood—nowhere more so than in the infant population. Noxious procedures are repeatedly performed on infants in hospital, and the short-term and long-term consequences of this are of increasing concern.1 Full-Text PDF