Question

• In term neonates, is oral glucose as efficacious as topical anesthetic cream in controlling pain at venipuncture?

Clinical Bottom Lines

1. The use of oral glucose with venipuncture significantly reduced signs of pain and length of crying in comparison to EMLA.
2. Oral glucose is simple to administer, has minimal to no side effects and is cost effective.
3. The opportunity for parents to provide and participate in their child's analgesia is empowering.

Summary of Key Evidence

1. 201 neonates from the NICU and maternity ward of two Swedish hospitals were enrolled. Criteria for enrollment were gestational age of >36 weeks, post-natal age >24hrs but <30 days. Exclusion criteria were assisted ventilation, neurologic symptoms, oxygen treatment, treatment for infection and sedative/analgesic use in the past 24hrs.¹
2. Patients were randomized to receive: a) 1cc 30% oral glucose and placebo cream, or b) oral placebo (1cc water) and EMLA prior to venipuncture for clinical purposes. Treatments were packaged identically to facilitate double-blinding.
3. EMLA or placebo was placed on the dorsal hand and occlusive dressing was removed after 60 minutes. Another 15 minutes was given to avoid venous constriction and possible irritation from removal of the dressing. During the procedure, a staff member or parent stood at the head and were encouraged to pacify the infant by giving a pacifier or their own finger to suck on. After obtaining the sample, the infant was left undisturbed on the nursing table for 3 minutes.
4. Heart rate and oximetry were monitored during the course of the procedure. Pain response was measured by duration of crying and by the Premature Infant Pain Profile (PIPP) scale (also validated for term infants²).
5. Significantly fewer patients in the glucose group were scored as having pain (PIPP greater than 6): 19.3% compared with 41.7% in the EMLA group (P = .0007) NNT = 5.
6. Duration of crying during the first 3 minutes was significantly shorter in the glucose group (median 1 second, range 0-180) than in the EMLA group (median 18 seconds, range 0-176); P =<.0001.
   

Additional Comments

• Studies indicate a lack of awareness among health care professionals of pain perception, assessment, and management in neonates
• AAP recommendations support the use of: 1) validated measures and assessment tools to evaluate and reduce the stress and pain experienced by neonates, 2) appropriate environmental, nonpharmacological (behavioral), and pharmacological interventions to prevent, reduce, or eliminate the stress and pain of neonates and 3) agents with known pharmacokinetic and pharmacodynamic properties and demonstrated efficacy in neonates.³
• Infants who have experienced pain during the neonatal period have been shown to respond differently to subsequent painful events. The use of appropriate analgesia ameliorates this outcome.

Citation

1. Gradin M, et al. Pain reduction at venipuncture in newborns: oral glucose compared with local anesthetic cream. Pediatrics 2002; 110:1053-1057.
2. Stevens B, Johnston C, Petryshen P, Taddio A. Premature Infant Pain Profile: development and initial validation. Clin J Pain. 1996;12:13-22.
3. American Academy of Pediatrics. Policy Statement: Evaluation and management of pain and stress in the neonate. Pediatrics 2000; 105:454-461.
   

CAT Author: Andre Krainik, MD

CAT Appraisers: Alex Kemper, MD

Date appraised: January 7, 2004