Non-pharmacologic management of procedure-related pain in the breastfeeding infant.

Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #23: Non-pharmacologic management of procedure-related pain in the breastfeeding infant. Breastfeed Med 2010 Dec;5(6):315-9.

Major Recommendations
Soothing the Newborn

There are several techniques that have been shown to provide pain relief for newborns (0–28 days of age) undergoing painful procedures. In breastfed newborns, breastfeeding itself is the preferred method to alleviate procedural pain. In addition to being safe, effective, natural, and without added cost, it provides an additional opportunity to promote and support breastfeeding. The individual components of breastfeeding (sucking, sweet taste, and warm contact) may be used separately or, preferably, in combinations when breastfeeding itself is not possible.

Breastfeeding or Human Milk

When available, breastfeeding should be the first choice to alleviate procedural pain in neonates undergoing a single painful procedure, such as venipuncture or heel lance (Codipietro, Ceccarelli, & Ponzone, 2008; Carbajal et al., 2003; Gray et al., 2002). Breastfeeding should not be discontinued prior to the procedure. Studies show that when breastfeeding was stopped shortly before a painful procedure, no significant differences were found (compared to control groups) in outcomes in terms of the orogustatory, emotional, tactile, or thermal experience (Gradin, Finnstrom, & Schollin, 2004). When breastfeeding is not possible, whether because of the unavailability of the mother or difficulties with breastfeeding, consider the use of expressed human milk by dropper, syringe, or bottle, which has been shown to soothe newborns experiencing procedural pain (Mathew & Mathew, 2003; Upadhyay et al., 2004; Taddio et al., 2008; Shah, Aliwalas, & Shah, 2006). Administration of human milk can also be combined with sucking, by dipping a pacifier (dummy) in the milk, as described below for sucrose.
Although some studies have demonstrated the efficacy of human milk alone (Upadhyay et al., 2004; Shah, Aliwalas, & Shah, 2007), human milk may not be equivalent to breastfeeding because of breastfeeding's multicomponent experience. Breastfeeding throughout the painful procedure is likely to be superior to human milk alone on the basis of synergism between the components of breastfeeding (Gradin, Finnstrom, & Schollin, 2004; Shah, Aliwalas, & Shah, 2007).
Skin-to-Skin Contact

Coordinating a breastfeeding session with the timing of the procedure is best, but, if this is not possible, skin-to-skin contact can comfort infants undergoing a procedure such as a heel lance. Skin-to-skin contact also gives the mother a caretaking role during the procedure that is unobtrusive, and by diminishing infant stress, it can increase maternal confidence as to her value to the infant (Gray, Watt, & Blass, 2000).
Parental contact and sucrose may act synergistically to reduce pain in neonates. Therefore if feasible, this combination can be employed (Schechter et al., 2007). Sucrose taste—first studied 20 years ago—is readily available for increasing the efficacy of other non-pharmacologic techniques (Gradin, Finnstrom, & Schollin, 2004). Sucrose administration is covered in more detail in the section below. Sucrose and pacifier can both be combined with the skin-to-skin component of parental contact.
Sucrose and Sucking (in Combination or Separately)

Sucrose taste has been shown to be effective analgesia for newborns and young infants for minor procedures, but not for more painful experiences like bladder catheterizations:

Sucrose and pacifier. The combination of oral sucrose and pacifier or non-nutritive sucking is remarkably soothing (Blass & Watt, 1999). This technique offers pain reduction to infants undergoing a wide variety of painful procedures, including heel lance, umbilical or percutaneous venous or arterial catheter insertion, central venous line placement, subcutaneous or intramuscular injection, lumbar puncture, circumcision, and endotracheal suction (Anand, 2001; Stevens, Yamada, & Ohlsson, 2004; Stevens et al., 2005). Because pain reduction achieved when using both sucrose and non-nutritive sucking is similar to that with breastfeeding, using a pacifier (dummy) dipped in 24% sucrose (by weight) solution whenever breastfeeding is not possible is an effective option (Blass & Watt, 1999; Akman et al., 2002). Sucrose administration should begin 2 minutes prior to the procedure. If use of a pacifier is not an available or acceptable option, sucrose can also be combined with sucking by dipping a clean, gloved (or non-gloved parental) finger in the sucrose solution. If sucking a pacifier or finger is not an option, administer a sucrose solution orally before the procedure (Anand, 2001). When parents are present, they should be educated that sweet substances other than breast milk and pacifiers both are recommended in the newborn period only for procedural pain.
Glucose versus sucrose. Glucose has also been shown to be an acceptable and effective alternative analgesic (Axelin et al., 2009; Idam-Siuriun et al., 2008). Taste difference is not a factor. Studies in rat (Blass & Shide, 1994) and human (Okan et al., 2007) newborns have not shown a preference for sucrose over glucose. The commercial availability of sucrose (table sugar) may have increased its use.
Sucrose by syringe. If use of a pacifier is not possible, administer 0.5–2mL of a 24% sucrose solution orally via syringe 2 minutes before the painful procedure (Anand, 2001; Shann, 2007). Several 24% sucrose solutions are commercially available. Sucrose administered by oro- or nasogastric tube is not analgesic.
Pacifier alone. While pacifiers alone may decrease crying associated with painful procedures, they do not have the same effect on physiological parameters such as heart rate or vagal tone (Taddio, 2001: Porges & Lipsitt, 1993). Moreover, sucking a pacifier has been found to reduce pain only when the suck rate exceeds 30 sucks/minute (Stevens, Yamada, & Ohlsson, 2004). A pacifier (or clean gloved or parental finger) should be used as the sole soothing intervention only if breastfeeding, human milk, sucrose (or glucose), and skin-to-skin contact are unavailable because non-nutritive sucking has consistently been found to be better than no intervention at all (Pinelli, Symington, & Ciliska, 2002).
Sucrose better than human milk? At least one study indicates that sucrose is more effective than human milk, when both are administered orally via syringe, at reducing infants' cry time, recovery time (heart rate peak returns to baseline), and change in heart rate (Ors et al., 1999). The sugar in human milk is lactose, which has been shown to be an ineffective analgesic agent (Blass & Shide, 1994). The analgesic component of human milk may be attributed to its fat content or other constituent
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