Pediatric Pain Sourcebook: External Review Form
Submission # 28 Title: Behavioral Interventions Aimed to Decrease Infant Pain
Submitter: Elliott M. Blass and Lisa Watt, Adjunct Professor of Pediatrics (EMB), Department of
Pediatrics, Boston University School of Medicine, Boston, MA, USA
Review:
The submission does meet minimum standards for publication, however, the following issues must be
corrected or clarified:
1. I would delete the % quoted in the submitter?s commentary, especially in relation to circumcision where we
want to ensure that both pharmacologic and behavioral measures are implemented.
Pacifier Sucking
2. Clearly indicate if this protocol is for term or preterm neonates. If it extends to preterm neonates, caution
needs to be taken about recommending which pacifiers for which GA needs to be taken to ensure that very
tiny infants get very tiny pacifiers.
3. Preterm babies will not be able to suck for 40 sucks/ minute; again, the reader needs to know this clearly
refers to term infants and a modified rate may be reasonable for preterm infants.
4. A statement needs to be included in relation to circumcision that pacifiers should be part of a comprehensive
approach that includes pharmacologic and behavioral approaches to pain management.
Sucrose
5. I would delete 90% effectivness as this is not accurate across all studies.
6. Some studies indicate that 6-7.5% sucrose is not effective, so I would say 12-24%.
7. Reference could be made to the Cochrane Review by Stevens & Ohlsson (1999) which reviews all of the
sucrose studies.
8. Authors should state how sucrose solution (in addition to glucose solution) can be accurately and safely
prepared for use in the institutional setting.
9. Infants should be swaddled but not tightly swaddled (I?m concerned how this may be interpreted by some)
10. There is no evidence that heel warming is effective and this is being deleted from pain guidelines, so I would
delete.
Pacifier-Sucrose
This section is fine.
Bibliography;
Add Blass?s most recent 1999 reference; add Cochrane reference (as above).
Check for grammatical errors.
Reviewer?s commentary detailing what they perceive to be the document?s applicability, strengths and
weaknesses, and necessary cautions.
Sucrose, with and without pacifiers, has been extensively evaluated in terms of its effectiveness for reducing
pain associated with procedures in both term and preterm neonates. In spite of the extensive amount of existing
research, there are not clear protocols which would guide practice in the clinical setting. Therefore, this protocol
fills an important need for clinicians from many disciplines who could implement these interventions in their
attempts to attenuate pain in this population. Dr. Blass did much of the original research on sucrose and pacifiers
and therefore would be considered one of the world?s experts on these interventions and their underlying
mechanisms. Therefore, he is an ideal person to contribute this protocol. There are only minor changes that I
believe would enhance what has been submitted. Generally, I would like a few clarifications and updates. Most
importantly, I would like to the authors to stress that sucrose and pacifiers, alone or in combination, although
effective for some less invasive procedures such as heel lance, should not solely be used for more invasive
procedures such as circumcision where a more comprehensive approach that includes both pharmacologic and
behavioral approaches should be implemented. Clear distinctions between use in the term and preterm infant
should also be addressed, especially for very preterm infants. This protocol will be most welcomes by clinicians
and researchers alike.
Keywords selected by the reviewer to describe the document.
Intended audience: families, healthcare professionals
Institution type: children?s hospital, general hospital
Drug type: Non-drug
Pain type: procedural, treatment related
Delivery technique: oral
Nonpharmacological treatments: behavioral
Age: neonate
Disease type: other — many associated with neonatal and perinatal medicine
Reviewer: Bonnie Stevens, PhD, Professor, Faculty of Nursing, University of Toron
Date: January 23, 2000
Protocol Descriptions:
Pacifier Sucking: For parents who are not willing for their child to taste a sweet solution,
pacifier sucking is a reasonable alternative. Pacifiers provided by the hospital are adequate.
The pacifier should be gently inserted into the infant?s mouth for the 2 min. Preceding heel
lance and should be returned if it falls out either before, during or for the 5 min. Following
the procedure. Care should be taken to insure that a rate exceeding 40
sucks/min is
achieved. For slower infants this can be realized by gently spinning the pacifier or slowly
moving it in and out. A pacifier has also been used to reduce crying during circumcision.
It should be given to the infant before he is placed on the restraining board. The same
procedures should be followed regarding pacifier loss.
Sweet Solutions: These are effective in over 90% of the cases reported in both term and
preterm infants. The dose response function is flat from 6% till about 30% concentration at
50-70% reduction, at which point it increases again.
Sucrose has been used most
frequently in a 12% Weight/Volume proportion. Glucose can be diluted from concentrated
stock concentration. A solution can be warmed after drawing it into the syringe.
For term infants undergoing heel lance, solution is offered for the 2 min. preceding
the procedure at a rate of 1
ml./min. Solution is not offered during the procedure. In all
instances of pacifier or sucrose administration, the infant should be tightly swaddled and
the heel warmed for 5 min. before the procedure. Delivery rate for premature infants
should proceed on a per case basis. Sugars alone have not been administered before
circumcision to avoid aspiration difficulties.
Pacifier-Sucrose: The combination is the most effective behavioral intervention. The
pacifier is dipped in the solution every thirty seconds. Using two pacifiers per infant is
most efficient. Suck rate is not related to efficacy of the combination stimulus. The
pacifier is returned if it has been spit out.
Bibliography
1. Blass, E. M. (1996). Mothers and their infants: Peptide-mediated physiological, behavioral
and affective changes during suckling.
Regulatory Pentides, 66, 109- 112.
2. Ren, K., Blass, E. M., Zhou, Q-q.,
& Dubner, R. (1997). Suckling and sucroses ingestion
suppress persistent hyperalgesia and spinal Fos expression after forepaw inflamation in infant r
Proceedings of the National Academy of Sciences,
104, 1471-1475.
Pediatric Pain Sourcebook: Submission Form
Name of submitter: Elliott M. Blass and Lisa Watt
Title of submitter: Adjunct Professor of Pediatrics (EMB)
Address: Department of Pediatrics, Boston University School of Medicine
Maternity 6, 91 East Concord Street
City: Boston State/Prov: MA Country: USA Postal/Zip code: 02118
Telephone: 617.414.7906 Fax: 617.414.7297 E-mail: lisabeth@bu.edu (LW)
This is a protocol:: pamphlet99 policy99 other 99 : guidelines
Title of document: Behavioral Interventions Aimed to Decrease Infant Pain
Approval and revision dates:
Behavioral interventions aimed to decrease infant pain
Purpose of document:
Institutional affiliation: Boston Medical Center
Type of institution:
Supervising specialist availability:
Number of pediatric beds:
Keywords describing the document.
Intended audience: healthcare professionals
Institution type: children?s hospital
Drug type:
Pain type: procedural
Delivery technique:
Nonpharmacological treatments: behavioural
Age: neonate
Disease type:
Submitter’s commentary:
Three behavioral protocols for reducing pain that is routinely encountered by premature and term infa
are described. Pain relieving effects of sweet taste and nonnutritive sucking have been documented
rat and human infants during the past decade (1) and a mechanism has been provided (2). Sucking a
sweet pacifier eliminates crying to heel lance in 80% of the infants whom we have studied and grima
in 60%. It is also very effective against the trauma of more invasive procedures such as circumcision
reducing crying by 70% of control values and 50% of infants sucking an unsweetened pacifier. The
intervention should be used in conjunction with physiological interventions such as dorsal penile nerv
block or application of EMLA cream. Neither of these procedures alleviate procedural stress caused
prolonged restraint and handling.
References used in preparing protocol: see protocol
