Analgesic Effect of Breast Milk

Versus Sucrose for Analgesia

During Heel Lance in Late Preterm

Infants Eva Simonse, Paul G. H. Mulder and Ron H. T. van Beek

Pediatrics 2012

Presented by :

Argadia Yuniriyadi, dr.

Original Article…

Backgrounds

Pain on infant

– Invasive Medical Procedure

– Other discomfort condition reaction

- Behavior (crying)

- Physical (tachycardia, >stomach acid, etc)

Backgrounds

Need :

PAIN MANAGEMENT

PAIN IN INFANT

• Ethical

• Repeated Pain Stimulus

– Long term child pain

responds dysfunction (hypersensitive, over reaction)

(Mancuso et al, 2009; Fitzgerald, 2001; Grunau et al, 2006)

Background

Skin to skin Pacifier

Sucrose

Breastfeeding

(sweet oral)

Drugs

PAIN MANAGEMENT

Breast Milk Vs Sucrose

• Both are the sweet oral liquid

– How they efficacy for pain in the infant?

• Long term sucrose use

BREAST MILK

• Breastfeeding or Bottled

Background

Premature Infant

• >> more invasive medical procedural needs

• Important risk infant group

Comparing the analgesic effect

Breastfeeding VS Sucrose on preterm

infant

.. .. .. Method

Inclusion & Exclusion

Criteria

Assessed for eligibility

Patient Randomly Assigned

Breastfeeding Supplemental

Breast Milk Sucrose

Study Design Randomized Controlled Trial

Time January 2010 to May 2011

Place Amphia Hospital, Breda,

Netherlands.

Subject

• GA 32+0 and 36+6 weeks,

• were being nourished with breastfeeding,

• had to have a clinical blood sample taken (Diagnose & Screening)

• perinatal asphyxia, birth trauma,

• Cardiorespiratory instability,

• Gastroesophageal reflux disease,

• drug abuse by the mother,

• Sedative medication to mother or child

Inclu

sio

n

Exc

lusio

n

Assessed for eligibility

Patient Randomly Assigned

Monitoring before HL :

- HR

- O2

Breastfeeding

• Mother’s arm

Supplemental Feed

• Held by a nurse

• Breast-milk

• Sterile syringe

Sucrose

• 1-2 ml sucrose 24 %

• 2 minutes before

USING :

an automated

piercing device

3 observer

OUTPUT Score

• Premature Infant Pain Profile

(PIPP) Postmenstrual age, behavioral state, heart rate, oxygen

saturation, and 3 facial actions

• COMFORTneo alertness, calmness, respiratory response or crying, body

movement, facial tension, and muscle tone

3 observer

Unadjusted score analyses analysis of variance.

Adjusted score analysis analysis of covariance

to adjust the estimated effects for the following co-

variables

OUTCOME

RESULT .. .. ..

• Refuse for participate (n=20)

• Breastfeeding difficulty (n=20)

• Unavailable of operator (n=10)

• No breast feeding (n = 229)

• TOTAL excluded ; 279

Treatment failure (2)

Analyzed (23)

No failure

Analyzed (23)

No Failure

Exclusion (1)

Analyzed (24)

Assessed for eligibility (n = 350)

Patient Randomly Assigned (n = 71)

Breastfeeding

(n = 23)

Supplemental

Breast Milk (n = 23)

Sucrose

(n = 25)

Baseline Criteria

“There were no

differences

between group

PIPP Score

Group n Unadjusted Adjusted

Group 1 23 7,00 (5,28-8,73) 7,04 (5,27-8,81)

Group 2 23 5,38 (3,65-7,01) 5,11 (3,39-6,84)

Group 1+2 46 6,19 (4,97-7,41) 6,08 (4,85-7,30)

Group 3 24 5,25 (3,56-6,94) 5,47 (3,74-7,20)

Outcome Comparing Point Difference

Unadjusted Adjusted

Primary (Group 1+2) and

Group 3

0,94 (-1,15 to 3,02)

(p=0,37)

0,61 (-1,57 to 2,78)

(p=0,58)

Secondary Group 1 and

Group 2

1,62 (-0,82 to 1,93)

(p=0,19)

1,93 (-0,57 to 4,42

(p=0,13)

“There were no

differences

between group

COMFORT Neo Score

Group n Unadjusted Adjusted

Group 1 23 18,6 (16,9 to 20,3) 19,0 (17,3 to 20,7)

Group 2 23 16,5 (14,8 to 18,2) 16,3 (14,6 to 18,0)

Group 1+2 46 17,5 (16,4 to 18,7) 17,7 (16,5 to 18,8)

Group 3 24 16,0 (14,4 to 17,7) 15,8 (14,1 to 17,5)

Outcome Comparing Point Difference

Unadjusted Adjusted

Primary (Group 1+2) and

Group 3

1,5 (- 0,5 to 3,5)

(p=0,14)

1,8 (-0,3 to 4,0)

(p=0,092)

Secondary Group 1 and

Group 2

2,1 (-0,3 to 4,4)

(p=0,09)

2,7(0,3 to 5,1)

(p=0,03)

“There were no

differences

between Breast

milk and Sucrose

group

The BREAST FEEDING’s adjusted Comfort neo score were significantly

HIGHER (worse) than Supplemental Feeding

1. Breast feeding and

Supplemental breast milk

• Clinical Practice :

– Breast milk can give breastfed or bottle-fed

– Depend on mother attendance

• Skin to skin (breastfed), can be relief the

pain so it’s assumed to be a better way

– But the PIPP score is not significantly

different.

2. PIPP and COMFORT neo,

• PIPP Primary assessment tool in research setting – Higher ICC point

– But less applicable.

• COMFORTneo

– More applicable,

– Because it didn’t need to measure HR and O2 saturation

• PIPP and COMFORTneo

– Correlation coefficient 2; moderate corelation

3. Sucrose as a pain relief in

infant

• Sucrose group had a lower PIPP score

Than water, pacifier, or positioning (Steven B et.al., 2010)