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QUESTION: In full term newborns having venipuncture, what are the analgesic effects of glucose, sucrose, and pacifiers?
Design
Randomised (allocation concealed*), blinded (outcome assessor was blinded to type of solution but not to the pacifier),* placebo controlled trial.
Setting
Maternity ward of a hospital in Poissy, France.
Patients
150 eligible newborns (59% boys) who had a 5 minute Apgar score ≥7, were medically stable, had not received naloxone during the previous 24 hours, and were not fed in the previous 30 minutes. 50 eligible newborns were not randomised because of non-availability of the observer (investigator).
Intervention
Infants were allocated to 1 of 6 groups with 25 infants each: no treatment, placebo (2 ml of sterile water), 2 ml of 30% glucose, 2 ml of 30% sucrose, a pacifier, and 2 ml of 30% sucrose and a pacifier. The solutions or pacifiers were given 2 minutes before venipuncture.
Main outcome measure
Pain during venipuncture and blood collection using the Douleur Aiguë du Nouveau-né (DAN) scale, a pain score (0=no pain, 10=maximum pain) based on facial expression, limb movements, and vocal expression.
Main results
The groups receiving glucose, sucrose, pacifiers, and sucrose plus pacifier had lower pain scores than the placebo group (p≤0.01) (table). The pacifier group hadlower pain scores than the glucose or sucrose groups (p≤0.001); pacifier and sucrose plus pacifier groups did not differ (p=0.06) (table).
Median pain scores during venipuncture for newborns using the Douleur Aiguë du Nouveau-né (DAN) scale†
Conclusions
In newborns having venipuncture, use of glucose and sucrose solutions and pacifiers reduced pain. Pacifiers were more effective than sweet solutions.
Commentary
Effective measures to minimise pain and discomfort in newborn infants having procedures are of recognised importance.1 Carbajal et al compared “sweeteners” with pacifiers and placebo in newborn infants having venipuncture.
The investigators used a 10 point evaluation tool for measuring pain (facial expression, limb movements, and vocal expression) recently reported by the principal investigator to have high internal consistency and interrater agreement2; no demonstrated correlation with biochemical markers of stress exists. In this randomised controlled trial, the investigators recognise a potential bias with the use of pacifiers not being blinded. It is reassuring, however, that the differences between the pacifier and placebo groups were greater than those between the pacifier and sweet solutions groups.
Potential mechanisms of action of pacifiers (sensory dominance or facilitated self regulation) are addressed in the article's discussion. Efficacy in preterm infants and during such other procedures as heel lancing remains to be determined. While the use of pacifiers for newborn infants is often discouraged, this study shows that pacifiers are more effective than 30% glucose or 30% sucrose solutions, a finding that should stimulate clinical practice changes for newborn infants having venipuncture.
Footnotes
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Source of funding: no external funding.
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For correspondence: Dr R Carbajal, Department of Paediatrics, Poissy Hospital, 78300 Poissy, France. Fax +33 1 39 27 44 33.