Key message: if your baby has to have a painful procedure, evidence shows that there are things you can do to minimise their pain, including holding their bare chest to yours, giving a sugar solution or breast milk and allowing them to suck or to breastfeed.
Nothing cuts a parent to the quick like seeing their child in pain, especially new mums (in whom, as I well remember, even the mildest news item can prompt a fresh bout of weeping). We’d rather take anything ourselves than have our children suffer, even briefly, wouldn’t we? For babies born prematurely or in need of medical intervention, potentially painful procedures go with the territory. Giving painkilling drugs can be problematic and creams that numb the skin have not been shown to be effective for premature babies who spend their first days or weeks in Neonatal Intensive Care Units, where lots of invasive procedures are part of their care. The good news is we have evidence to show that there are other things we can do to help minimise discomfort for these little ones.
Take your cue from a kangaroo!
A new Cochrane review has found that skin-to-skin care, also known as Kangaroo Care, where mum (or another person) holds the baby’s bare chest to hers, seems to be both safe and effective for reducing a newborn’s pain from a single procedure such as a heel prick or injection. Because the 19 studies included in this review varied a lot, few results could be combined to provide stronger evidence. It’s not possible to know from this evidence how much benefit skin-to-skin care offers, but the results are in its favour.
Babies’ pain can be measured by studying physical things such as their heart rate and also behaviour (such as grimacing and crying – though preterm babies cry less than full term babies in response to pain); these are sometimes combined in scoring systems such as the Premature Infant Pain Profile (PIPP), used in many of the studies in these reviews.
An earlier review on kangaroo mother care, comprising skin-to-skin contact, frequent and exclusive or near-exclusive breastfeeding and early discharge from hospital, found evidence to support its use as an alternative to conventional neonatal care for stabilized low birthweight babies, mainly in resource limited countries.
A spoonful of sugar?
Well, perhaps not a spoonful, but giving newborn babies sugar on a dummy or into their mouths by a dropper or syringe has been shown to be effective and safe for reducing pain from a single, and to a lesser extent, repeated heel pricks. The evidence comes from 57 randomized trials in a newly-updated review. Giving sugar to babies two minutes before the painful procedure brings the greatest benefit and the effect lasts around four minutes. The review also includes studies exploring whether this helps in other painful procedures, but the evidence is conflicting and needs investigating further. The review authors say that combining methods, such as giving sugar and providing skin-to-skin contact, is really worth considering and may offer very good pain relief.
Sugary solutions may also help reduce needle-related pain in babies aged one month to a year and they have been found to cry for a shorter time than babies given water, but the evidence included in the review on this isn’t good enough to be sure that this is an effective technique. It looks promising though, so let’s hope more good trials are being done which will give us some clear answers, not just about how well this works but to find the best doses, timing and ways of giving the sugar and whether there are any side effects.
Does this work for older children having needle procedures? A review asking this question found that there’s too little evidence to answer it. Other alternatives to medicines for pain relief in babies and young children were considered in another review. It has evidence in favour of kangaroo care, non-feeding sucking and swaddling for preterm babies, and allowing the baby to suck for at least three minutes before the painful procedure may be particularly effective. Non-feeding sucking was also helpful for newborns, but there wasn’t clear evidence about what works for older babies.
Breast milk can help too
Another review investigated whether breastfeeding or supplemental breast milk helped reduce pain in newborns. All of the babies studied were born at full term and were having a needle procedure. Breastfeeding was found to be a good way of relieving pain and better than sucking on a dummy, being held, or being swaddled and placed in a crib. Sugar and breastfeeding were similarly effective. The results for supplemental breast milk were mixed; it seemed to be better than water or massage but not as good as sugar.
So there’s lots you can do to make your baby more comfortable during painful procedures
Although there are still gaps in what we know and scope for more research to be done, the evidence we have so far tells us that skin-to-skin contact, sugar solutions, breastfeeding and non-feeding sucking, breast milk and swaddling can all help reduce pain in babies and provide a good alternative to medicines and creams.
This knowledge is only useful, though, if parents and practitioners use it! The Cochrane Neonatal Group team behind the review of sugar for pain relief in newborn babies note that despite the inclusion of the evidence supporting this method in guidelines for health practitioners, a survey of practice in Neonatal Intensive Care Units showed that it was rarely used, so ways need to be found to increase its use. I hope lots of health practitioners and parents will read this and spread the word to others.
Has your baby spent time in hospital? Have you tried any of these methods of comforting your baby during a painful procedure? Did anyone suggest them to you? Nurses, do you use these techniques with the babies in your care? We’d be really interested to hear your experiences.
Johnston C, Campbell-Yeo M, Fernandes A, Inglis D, Streiner D, Zee R. Skin-to-skin care for procedural pain in neonates. Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD008435. DOI: 10.1002/14651858.CD008435.pub2.
Conde-Agudelo A, Belizán JM, Diaz-Rossello J. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No.: CD002771. DOI: 10.1002/14651858.CD002771.pub2.
Stevens B, Yamada J, Lee GY, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD001069. DOI: 10.1002/14651858.CD001069.pub4.
Kassab M, Foster JP, Foureur M, Fowler C. Sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD008411. DOI: 10.1002/14651858.CD008411.pub2.
Harrison D, Yamada J, Adams-Webber T, Ohlsson A, Beyene J, Stevens B. Sweet tasting solutions for reduction of needle-related procedural pain in children aged one to 16 years. Cochrane Database of Systematic Reviews 2011, Issue 10. Art. No.: CD008408. DOI: 10.1002/14651858.CD008408.pub2.
Pillai Riddell RR, Racine NM, Turcotte K, Uman LS, Horton RE, Din Osmun L, Ahola Kohut S, Hillgrove Stuart J, Stevens B, Gerwitz-Stern A. Non-pharmacological management of infant and young child procedural pain. Cochrane Database of Systematic Reviews 2011, Issue 10. Art. No.: CD006275. DOI: 10.1002/14651858.CD006275.pub2.