Explanation: Oral Sucrose and Neonatal Pain

Thompson D.G. (2005) Utilizing an oral sucrose solution to minimize neonatal pain.Journal of Specialized Pediatric Nursing. Jan-Mar.10(1):3-10.

The administration of sucrose or the combination of sucrose with non-nutritive sucking is one of the most frequently studied nonpharmacologic interventions for the relief of procedural pain in neonates (Stevens, 1999). Research demonstrates that sucrose can safely and effectively provide analgesia for young infants receiving heel lancings and other painful procedures. It is thought that the analgesic effect of sucrose works on opioid receptors because in animal studies, this effect can be blocked by naloxone (Blass, Fitzgerald, & Kehoe, 1987). The age dependency of oral sucrose analgesia may be the result of developmental changes in the interaction between gustatory and pain pathways (Anseloni et al., 2002). The unique response of the neonate to an oral sucrose solution allows for a very safe and effective measure in minimizing procedural pain. (from pages 3-4)

D’Apolito K C. (2006) State of the science: procedural pain management in the neonate. Journal of Perinatal- Neonatal Nursing. Jan-Mar. 20(1). 56-61.

NONPHARMACOLOGIC TREATMENT OF PROCEDURAL PAIN

Nonpharmacologic treatments used to decrease neonatal procedural pain include oral sucrose, skin-to-skin contact, and breast-feeding. Most evidence has been reported regarding the benefit of administering oral sucrose 2 minutes before a painful procedure. Data are just becoming available regarding the efficacy of skin-to-skin contact or breast-feeding.

Oral sucrose

The calming effect of sucrose occurs through the release of endogenous opiates triggered by the sweet taste through taste receptors located at the tip of the tongue.55,56 Several studies have reported that 24% sucrose with nonnutritive sucking seems to be effective for reducing heel stick pain.40–42 Results were similar whether the neonate received 2 mL or 0.5 mL of sucrose solution.41,42

Sucrose solution has also been used to treat the pain associated with an eye examination for retinopathy of prematurity (classified as severe, Table 2). No significant differences in pain scores, heart rate, respiratory rate, or oxygen saturation were found when the administration of a 24% sucrose solution was compared to the administration of sterile water prior to this procedure.42 (from page 58)

Benis, M. (2002) Efficacy of sucrose as analgesia for procedural pain in neonates.Advances in Neonatal Care. Apr. 2(2). 93-100.

Analgesics may be employed for major procedures and postoperative pain, although use of analgesics for minor procedures is less frequent because of concerns about adverse effects or toxicity. Various nonpharmocologic methods have been used to decrease pain in infants, including nonnutritive sucking, containment, positioning, and vestibular activity. The most extensively studied intervention to decrease pain during procedures in infants is the administration of oral sucrose.

Sucrose administered orally before painful procedureshas shown a decrease in the following:

  • Duration of crying
  • Facial action associated with pain
  • Heart rate
  • Composite pain scores

The pain relief elicited by sucrose solutions is thoughtto be biphasic, with an immediate reabsorptive calmingeffect, followed by the activation of endogenous opioids. This second mechanism, involving the release of endorphinsthat decrease pain in infants, is supported by animalstudies that have shown that the analgesic effects ofsucrose can be blocked by administering an opioid antagonist. In addition, Blass and Ciaramitaro showed thatinfants born to methadone-dependent mothers were unresponsiveto the analgesic properties of sucrose. (from page 94)

Explanation: (separation) anxiety disorder and school refusal

Kearney, C.A. Addressing School Refusal Behavior: Suggestions for Frontline Professionals. Children & Schools, 2005 Oct; 27 (4): 207-16 (excerpt from page 207)

Hanna, G.L., Fischer, D.J., Fluent, T.E.Separation Anxiety Disorder and School Refusal in Children and Adolescents, Pediatrics in Review.2006;27:56-63

Separation anxiety disorder (SAD),however, is a common childhood anxiety disorder that often involvespersistent problems with attending school or other activitiesaway from home because of fear of separation. The fear associatedwith leaving the safety of parents and home may escalate intotantrums or panic attacks and cause significant interferencewith academic, social, or emotional development. (pg. 56)

Studies assessing childhood anxiety disorders have repeatedlydemonstrated that children who have SAD often have other psychiatricdisorders. In clinical samples of children who have SAD, approximately50% are diagnosed with at least one other anxiety disorder and34% with a depressive disorder. Studies of depressed prepubertalchildren have found concurrent separation anxiety disorder in40% to 60% of subjects. When SAD and a depressive disorder coexist,SAD precedes the depression in approximately 67% of cases. (pg. 58)

Definition: Laminectomy

Harvey, C.V., Spinal surgery patient care.Orthopaedic Nursing, 07446020, November 1, 2005, Vol. 24, Issue 6 (excerpt from page 433)

Laminectomy

This is the removal of part of the laminae and possibly a portion of the ligamentum flavum, facet joints, and any protruding osteophytes to allow room for nerve roots and to expose the abnormal part of the disc. This is often enough to decompress the affected nerve and relieve the symptoms. Pain relief is often not instantaneous postoperatively because it takes time for the inflammation to the nerve to subside. This is effective with spinal stenosis (Best, 2002).

Chen, A.L. and Spivak J.M. Degenerative lumbar spinal stenosis: options for aging backs.Physician & Sportsmedicine, 00913847, August 1, 2003, Vol. 31, Issue 8 (html, section “Operative Management,” paragraphs 4 & 6)

Laminectomy. The standard decompression procedure, called laminectomy, involves removal of the spinous processes and central portion of the laminae overlying the affected stenotic segments (figure 4). Hypertrophic arthritic facet joints are shaved to relieve compression along the central spinal canal, lateral recess, and neural foramen as needed.

The results of standard operative decompression for lumbar spinal stenosis are encouraging. One metaanalysis showed an average of 64% of patients had a good or excellent outcome after surgery.[sup26] Operatively managed patients have significantly better outcomes at 1-year evaluation when compared with nonoperatively treated patients, despite the fact that operative candidates tended to have increased symptoms before surgery. Risk factors associated with a worse outcome after operative management include diabetes mellitus, osteoarthritis of the hip, preoperative degenerative scoliosis, and preoperative lumbar fracture.[sup27,28]

Atlas, S. J., Delitto, A., Spinal Stenosis: Surgical versus Nonsurgical Treatment. Clinical Orthopaedics and Related Research. Volume 443,February 2006,pp 198-207 (excerpt from page 202)

Laminectomy

Broadly, surgical treatment is designed to alleviate compression on the neural tissues in the central canal and/or lateral recesses. Decompression or laminectomy of the lumbar spine at one or more levels has been the standard treatment for spinal stenosis involving the central canal despite little evidence from comparative trials of nonsurgical treatment or alternative surgical interventions.29 The operative challenge is to provide adequate decompression of the neural elements while maintaining spinal stability. Iatrogenic instability can be decreased by preserving the facet joint and the pars interarticularis. A variety of different surgical techniques, including laminotomy, laminarthrectomy, laminoplasty, and microscopic decompression have been reported with a general goal of providing adequate clinical outcomes with less invasive decompression.61,72 However, the relative effectiveness and complications of various decompressive procedures remain uncertain.30

There are no large randomized studies to show the relative benefit of surgical decompression compared to nonsurgical treatment. Short-term results from a randomized trial presented to date only as an abstract report improved outcomes associated with surgical treatment.54 Among published studies, a single randomized study compared 13 surgically treated and 18 nonsurgically treated patients with spinal stenosis.2 Although Amundsen et al 2 reported better outcomes with surgery, 56% of nonsurgically treated individuals crossed over to surgery after a median of only 3.5 months, outcomes were judged by physicians not patients, and no statistical comparisons were done.