Sucrose and oxidants

Abstract

Oral sucrose has been recommended for neonatal analgesia during procedural pain.1Batton D.G. Barrington K.J. Wallman C. Prevention and management of pain in the neonate: an update.Pediatrics. 2006; 118: 2231-2241Crossref PubMed Scopus (384) Google Scholar Asmerom et al have concluded that even a single dose of oral sucrose can significantly increase oxidative stress in premature infants and have thus, cautioned against its repeated use in neonates during painful procedures.2Asmerom Y. Slater L. Boskovic D.S. Bahjri K. Holden M.S. Phillips R. et al.Oral sucrose for heel lance increases adenosine triphosphate use and oxidative stress in preterm neonates.J Pediatr. 2013; 163: 29-35Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar However, attributing oxidative stress to sucrose appears inappropriate. Rather, a significant relationship between neonatal pain, due to tissue damaging procedures, and oxidative stress has been reported.3Slater L. Asmerom Y. Boskovic D.S. Bahjri K. Plank M.S. Angeles K.R. et al.Procedural pain and oxidative stress in premature neonates.J Pain. 2012; 13: 590-597Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar Hence, pain and tissue damage caused by heel lance rather than sucrose, is more likely to have been responsible for oxidative stress.Asmerom et al have reported a definite analgesic effect with sucrose compared with placebo.2Asmerom Y. Slater L. Boskovic D.S. Bahjri K. Holden M.S. Phillips R. et al.Oral sucrose for heel lance increases adenosine triphosphate use and oxidative stress in preterm neonates.J Pediatr. 2013; 163: 29-35Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar However, overall, there was no significant difference in rise in plasma allantoin concentration, a marker of oxidative stress, between the two groups.2Asmerom Y. Slater L. Boskovic D.S. Bahjri K. Holden M.S. Phillips R. et al.Oral sucrose for heel lance increases adenosine triphosphate use and oxidative stress in preterm neonates.J Pediatr. 2013; 163: 29-35Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Thus, the oxidative stress in the sucrose group was not greater than in the placebo group. In a subgroup analysis of neonates who demonstrated a minimal response to heel lance (increase in Premature Infant Pain Profile score of <33%), neonates administered sucrose had a significant rise in allantoin compared with placebo. The authors have attributed this to a greater oxidative stress following sucrose administration. However, the same can be interpreted differently.Painful response is usually related to the extent of tissue damage. The analgesic action of oral sucrose would dampen the painful response to tissue damage. Thus, for comparable painful responses, neonates in the sucrose subgroup would be expected to have greater tissue damage than neonates in the placebo subgroup. It is likely that the greater oxidative stress, noted in sucrose subgroup with minimal response to pain, was due to relatively greater tissue damage and not sucrose administration. The study by Asmerom et al should, hence, not prevent neonatologists from using oral sucrose for procedural pain. Oral sucrose has been recommended for neonatal analgesia during procedural pain.1Batton D.G. Barrington K.J. Wallman C. Prevention and management of pain in the neonate: an update.Pediatrics. 2006; 118: 2231-2241Crossref PubMed Scopus (384) Google Scholar Asmerom et al have concluded that even a single dose of oral sucrose can significantly increase oxidative stress in premature infants and have thus, cautioned against its repeated use in neonates during painful procedures.2Asmerom Y. Slater L. Boskovic D.S. Bahjri K. Holden M.S. Phillips R. et al.Oral sucrose for heel lance increases adenosine triphosphate use and oxidative stress in preterm neonates.J Pediatr. 2013; 163: 29-35Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar However, attributing oxidative stress to sucrose appears inappropriate. Rather, a significant relationship between neonatal pain, due to tissue damaging procedures, and oxidative stress has been reported.3Slater L. Asmerom Y. Boskovic D.S. Bahjri K. Plank M.S. Angeles K.R. et al.Procedural pain and oxidative stress in premature neonates.J Pain. 2012; 13: 590-597Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar Hence, pain and tissue damage caused by heel lance rather than sucrose, is more likely to have been responsible for oxidative stress. Asmerom et al have reported a definite analgesic effect with sucrose compared with placebo.2Asmerom Y. Slater L. Boskovic D.S. Bahjri K. Holden M.S. Phillips R. et al.Oral sucrose for heel lance increases adenosine triphosphate use and oxidative stress in preterm neonates.J Pediatr. 2013; 163: 29-35Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar However, overall, there was no significant difference in rise in plasma allantoin concentration, a marker of oxidative stress, between the two groups.2Asmerom Y. Slater L. Boskovic D.S. Bahjri K. Holden M.S. Phillips R. et al.Oral sucrose for heel lance increases adenosine triphosphate use and oxidative stress in preterm neonates.J Pediatr. 2013; 163: 29-35Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Thus, the oxidative stress in the sucrose group was not greater than in the placebo group. In a subgroup analysis of neonates who demonstrated a minimal response to heel lance (increase in Premature Infant Pain Profile score of <33%), neonates administered sucrose had a significant rise in allantoin compared with placebo. The authors have attributed this to a greater oxidative stress following sucrose administration. However, the same can be interpreted differently. Painful response is usually related to the extent of tissue damage. The analgesic action of oral sucrose would dampen the painful response to tissue damage. Thus, for comparable painful responses, neonates in the sucrose subgroup would be expected to have greater tissue damage than neonates in the placebo subgroup. It is likely that the greater oxidative stress, noted in sucrose subgroup with minimal response to pain, was due to relatively greater tissue damage and not sucrose administration. The study by Asmerom et al should, hence, not prevent neonatologists from using oral sucrose for procedural pain. Oral Sucrose for Heel Lance Increases Adenosine Triphosphate Use and Oxidative Stress in Preterm NeonatesThe Journal of PediatricsVol. 163Issue 1PreviewTo examine the effects of sucrose on pain and biochemical markers of adenosine triphosphate (ATP) degradation and oxidative stress in preterm neonates experiencing a clinically required heel lance. Full-Text PDF ReplyThe Journal of PediatricsVol. 164Issue 1PreviewWe agree with the statement by Keshvani that untreated procedural pain can increase oxidative stress, as published by our laboratory1 and others.2 However, we want to address the comment on the subgroup analysis, which included neonates whose pain score increased minimally (<33% increase in Premature Infant Pain Profile score) in response to a single heel lance. This subgroup of neonates included control subjects who received no heel lance (n = 19) and 2 groups of neonates who received a single heel lance, 2 minutes after receiving either placebo and non-nutritive sucking (n = 19) or sucrose (Sweet-Ease; Children's Medical Ventures, Phillips Healthcare, Andover, Massachusetts) and non-nutritive sucking (n = 27). Full-Text PDF