PEDIATRICS Vol. 121 No. 6 June 2008, pp. 1295 (doi:10.1542/peds.2008-0898)
LETTER TO THE EDITOR |
Analgesic Properties of Oral Sucrose During Routine Immunizations: In Reply
Linda A. Hatfield, PhD, CRNPSchool of Nursing
College of Health and Human Development
Pennsylvania State University
University Park, PA 16802
Maryellen E. Gusic, MD
Division of General Pediatrics
College of Medicine
Penn State Children's Hospital
Hershey, PA 17033
Rosemary C. Polomano, PhD, RN, FAAN
Biobehavioral Health Sciences
University of Pennsylvania
Philadelphia, PA 19104-6096
Cheston M. Berlin, MD
Division of General Pediatrics
College of Medicine
Penn State Children's Hospital
Hershey, PA 17033
We appreciate the views expressed by Dr Dilli in response to our study1 and wish to clarify several points that were made. First, early investigators of sucrose analgesia considered proportion, percentage, or duration of cry to be valid indicators of pain in infants.2–4 Cry may give some indication of pain or distress5; however, cry alone does not confirm or deny infant pain. Allen et al4 reported that 12% sucrose (not the 24% used in our investigation) was no more effective than sterile water in reducing pain in infants and toddlers. This finding must be interpreted cautiously given that cry duration was the only end point of this study, whereas our study's end point was a multidimensional behavioral assessment of pain.
Second, Dr Dilli cited a study that supported the analgesic properties of 75% oral sucrose after infant immunizations,2 which has been criticized for its misuse of the Oucher scale,6 a self-report tool intended for use by verbal children between the ages of 3 and 12 years. The scale has not been validated for use by adults who attempt to match the face of the infant to a photograph on the measure.7 We believe the methods discussed in our article are directly relevant to the efficacy of oral sucrose analgesia for infants during immunizations.
Third, our decision to use a 24% sucrose solution with preservatives was based on the commercial availability of this concentration in the United States and data suggesting that in healthy, term infants, doses of 
24% were most effective. Reductions in crying time with concentrations of sucrose at 48% to 50% were not statistically significant.8 In addition, studies have shown that a 10% sucrose solution prepared and correctly stored in a unit refrigerator displayed significant bacterial contamination <24 hours after preparation.9 We agree with Dr Dilli that reduction of infant pain and distress is best accomplished with the lowest concentration of clinically effective sucrose solution. We balanced this objective with the microbiologic safety of the solution administered to infants.
Last, we agree that lidocaine-prilocaine cream may be equally effective as oral sucrose in relieving pain and distress associated with injections, as noted in Dr Dilli's experience. However, this preparation must be applied 60 minutes before injection, which makes it a less favorable alternative for busy clinical practices.10 More randomized, controlled trials are needed to answer important questions regarding the comparability of acceptable analgesic options for alleviating pain and distress with immunizations.
REFERENCES
- Hatfield LA, Gusic ME, Dyer AM, Polomano RC. Analgesic properties of oral sucrose during routine immunizations at 2 and 4 months of age. Pediatrics. 2008;121 (2). Available at: www.pediatrics.org/cgi/content/full/121/2/e327
- Lewindon PJ, Harkness L, Lewindon N. Randomised controlled trial of sucrose by mouth for the relief of infant crying after immunisation.
Arch Dis Child. 1998;78
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[Abstract/Free Full Text] - Barr RG, Young SN, Wright JH, et al. "Sucrose analgesia" and diphtheria-tetanus-pertussis immunizations at 2 and 4 months. J Dev Behav Pediatr. 1995;16 (4):220 –225[Web of Science][Medline]
- Allen KD, White DD, Walburn JN. Sucrose as an analgesic agent for infants during immunization injections.
Arch Pediatr Adolesc Med. 1996;150
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[Abstract/Free Full Text] - Fuller BF. Acoustic discrimination of three types of infant cries. Nurs Res. 1991;40 (3):156 –160[Web of Science][Medline]
- Beyer JE, Turner SB, Jones L, Young L, Onikul R, Bohaty B. The alternate forms reliability of the Oucher pain scale. Pain Manag Nurs. 2005;6 (1):10 –17[CrossRef][Medline]
- Choonara I, Beyer JE. Randomised controlled trial of sucrose by mouth for the relief of infant crying after immunisation.
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[Free Full Text] - Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev. 2004;(3):CD001069
- Abu-Arafeh I, Callaghan M, Hill A, Hislop S. Randomised controlled trial of sucrose by mouth for the relief of infant crying after immunisation.
Arch Dis Child. 1998;79
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[Free Full Text] - Lindh V, Wiklund U, Blomquist HK, Håkansson S. EMLA cream and oral glucose for immunization pain in 3-month-old infants. Pain. 2003;104 (1–2):381 –388[CrossRef][Web of Science][Medline]
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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