Pediatric Pain Sourcebook: External Review Form
\nSubmission # 28 Title: Behavioral Interventions Aimed to Decrease Infant Pain
\nSubmitter: Elliott M. Blass and Lisa Watt, Adjunct Professor of Pediatrics (EMB), Department of
\nPediatrics, Boston University School of Medicine, Boston, MA, USA
\nReview:
\nThe submission does meet minimum standards for publication, however, the following issues must be
\ncorrected or clarified:
\n1. I would delete the % quoted in the submitter?s commentary, especially in relation to circumcision where we
\nwant to ensure that both pharmacologic and behavioral measures are implemented.
\nPacifier Sucking
\n2. Clearly indicate if this protocol is for term or preterm neonates. If it extends to preterm neonates, caution
\nneeds to be taken about recommending which pacifiers for which GA needs to be taken to ensure that very
\ntiny infants get very tiny pacifiers.
\n3. Preterm babies will not be able to suck for 40 sucks\/ minute; again, the reader needs to know this clearly
\nrefers to term infants and a modified rate may be reasonable for preterm infants.
\n4. A statement needs to be included in relation to circumcision that pacifiers should be part of a comprehensive
\napproach that includes pharmacologic and behavioral approaches to pain management.
\nSucrose
\n5. I would delete 90% effectivness as this is not accurate across all studies.
\n6. Some studies indicate that 6-7.5% sucrose is not effective, so I would say 12-24%.
\n7. Reference could be made to the Cochrane Review by Stevens & Ohlsson (1999) which reviews all of the
\nsucrose studies.
\n8. Authors should state how sucrose solution (in addition to glucose solution) can be accurately and safely
\nprepared for use in the institutional setting.
\n9. Infants should be swaddled but not tightly swaddled (I?m concerned how this may be interpreted by some)
\n10. There is no evidence that heel warming is effective and this is being deleted from pain guidelines, so I would
\ndelete.
\nPacifier-Sucrose
\nThis section is fine.
\nBibliography;
\nAdd Blass?s most recent 1999 reference; add Cochrane reference (as above).
\nCheck for grammatical errors.
\nReviewer?s commentary detailing what they perceive to be the document?s applicability, strengths and
\nweaknesses, and necessary cautions.
\nSucrose, with and without pacifiers, has been extensively evaluated in terms of its effectiveness for reducing
\npain associated with procedures in both term and preterm neonates. In spite of\u00a0 the extensive amount of existing
\nresearch, there are not clear protocols which would guide practice in the clinical setting. Therefore, this protocol
\nfills an important need for clinicians from many disciplines who could implement these interventions in their
\nattempts to attenuate pain in this population. Dr. Blass did much of the original research on sucrose and pacifiers
\nand therefore would be considered one of the world?s experts on these interventions and their underlying
\nmechanisms. Therefore, he is an ideal person to contribute this protocol. There are only minor changes that I
\nbelieve would enhance what has been submitted. Generally, I would like a few clarifications and updates. Most
\nimportantly, I would like to the authors to stress that sucrose and pacifiers, alone or in combination, although
\neffective for some less invasive procedures such as heel lance, should not solely be used for more invasive
\nprocedures such as circumcision where a more comprehensive approach that includes both pharmacologic and
\nbehavioral approaches should be implemented. Clear distinctions between use in the term and preterm infant
\nshould also be addressed, especially for very preterm infants. This protocol will be most welcomes by clinicians
\nand researchers alike.<\/p>\n
Keywords selected by the reviewer to describe the document.
\nIntended audience: families, healthcare professionals
\nInstitution type: children?s hospital, general hospital
\nDrug type: Non-drug\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0
\nPain type: procedural, treatment related
\nDelivery technique: oral
\nNonpharmacological treatments: behavioral\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0
\nAge: neonate
\nDisease type: other — many associated with neonatal and perinatal medicine\u00a0 \u00a0 \u00a0 \u00a0
\nReviewer: Bonnie Stevens, PhD, Professor, Faculty of Nursing, University of Toron
\nDate: January 23, 2000<\/p>\n
Protocol Descriptions:
\nPacifier Sucking: For parents who are not willing for their child to taste a sweet solution,
\npacifier sucking is a reasonable alternative. Pacifiers provided by the hospital are adequate.
\nThe pacifier should be gently inserted into the infant?s mouth for the 2 min. Preceding heel
\nlance and should be returned if it falls out either before, during or for the 5 min. Following
\nthe procedure. Care should be taken to insure that a rate exceeding 40
\nsucks\/min is
\nachieved. For slower infants this can be realized by gently spinning the pacifier or slowly
\nmoving it in and out. A pacifier has also been used to reduce crying during circumcision.
\nIt should be given to the infant before he is placed on the restraining board. The same
\nprocedures should be followed regarding pacifier loss.
\nSweet Solutions: These are effective in over 90% of the cases reported in both term and
\npreterm infants. The dose response function is flat from 6% till about 30% concentration at
\n50-70% reduction, at which point it increases again.
\nSucrose has been used most
\nfrequently in a 12% Weight\/Volume proportion. Glucose can be diluted from concentrated
\nstock concentration. A solution can be warmed after drawing it into the syringe.
\nFor term infants undergoing heel lance, solution is offered for the 2 min. preceding
\nthe procedure at a rate of 1
\nml.\/min.\u00a0 Solution is not offered during the procedure. In all
\ninstances of pacifier or sucrose administration, the infant should be tightly swaddled and
\nthe heel warmed for 5 min. before the procedure. Delivery rate for premature infants
\nshould proceed on a per case basis. Sugars alone have not been administered before
\ncircumcision to avoid aspiration difficulties.
\nPacifier-Sucrose: The combination is the most effective behavioral intervention. The
\npacifier is dipped in the solution every thirty seconds. Using two pacifiers per infant is
\nmost efficient. Suck rate is not related to efficacy of the combination stimulus. The
\npacifier is returned if it has been spit out.
\nBibliography
\n1. Blass, E. M. (1996). Mothers and their infants: Peptide-mediated physiological, behavioral
\nand affective changes during suckling.
\nRegulatory Pentides, 66, 109- 112.
\n2. Ren, K., Blass, E. M., Zhou, Q-q.,
\n& Dubner, R. (1997). Suckling and sucroses ingestion
\nsuppress persistent hyperalgesia and spinal Fos expression after forepaw inflamation in infant r
\nProceedings of the National Academy of Sciences,
\n104, 1471-1475.<\/p>\n
Pediatric Pain Sourcebook: Submission Form
\nName of submitter:\u00a0 Elliott M. Blass and Lisa Watt
\nTitle of submitter: Adjunct Professor of Pediatrics (EMB)
\nAddress: Department of Pediatrics, Boston University School of Medicine
\nMaternity 6, 91 East Concord Street
\nCity: Boston\u00a0 \u00a0 \u00a0 State\/Prov: MA\u00a0 \u00a0 Country: USA\u00a0 \u00a0 \u00a0 Postal\/Zip code: 02118
\nTelephone: 617.414.7906\u00a0 \u00a0 \u00a0 \u00a0 Fax: 617.414.7297\u00a0 \u00a0 \u00a0 E-mail: lisabeth@bu.edu (LW)
\nThis is a protocol::\u00a0 pamphlet99\u00a0 policy99\u00a0 \u00a0 other 99 :\u00a0 guidelines
\nTitle of document: Behavioral Interventions Aimed to Decrease Infant Pain
\nApproval and revision dates:
\n Behavioral interventions aimed to decrease infant pain
\nPurpose of document:
\nInstitutional affiliation: Boston Medical Center
\nType of institution:
\nSupervising specialist availability:
\nNumber of pediatric beds:
\nKeywords describing the document.
\nIntended audience: healthcare professionals
\nInstitution type: children?s hospital
\nDrug type:
\nPain type: procedural
\nDelivery technique:
\nNonpharmacological treatments: behavioural
\nAge: neonate
\nDisease type:
\nSubmitter’s commentary:
\nThree behavioral protocols for reducing pain that is routinely encountered by premature and term infa
\nare described. Pain relieving effects of sweet taste and nonnutritive sucking have been documented
\nrat and human infants during the past decade (1) and a mechanism has been provided (2). Sucking a
\nsweet pacifier eliminates crying to heel lance in 80% of the infants whom we have studied and grima
\nin 60%. It is also very effective against the trauma of more invasive procedures such as circumcision
\nreducing crying by 70% of control values and 50% of infants sucking an unsweetened pacifier. The
\nintervention should be used in conjunction with physiological interventions such as dorsal penile nerv
\nblock or application of EMLA cream. Neither of these procedures alleviate procedural stress caused
\nprolonged restraint and handling.
\nReferences used in preparing protocol: see protocol<\/p>\n","protected":false},"excerpt":{"rendered":"
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<\/p>\n