Combining oral 25% dextrose with skin-to-skin contact may provide better pain relief for term newborns

Article Outline

• Question
• Design
• Setting
• Participants
• Intervention
• Outcomes
• Main Results
• Conclusions
• Commentary
• Copyright

Chermont AG, Falcao LFM, de Souza Silva EHL, de Cassia Xavier Balda R, Guinsburg R. Skin-to-skin contact and/or oral 25% dextrose for procedural pain relief for term newborn infants. Pediatrics 2009;124:e1101-7.

Back to Article Outline

Question 

Among term newborns who are receiving an intramuscular injection of a hepatitis B vaccine, does a combination of oral 25% dextrose treatment and skin-to-skin contact provide better analgesia than either treatment alone?

Back to Article Outline

Design 

Prospective, randomized, partially blinded, clinical trial.

Back to Article Outline

Setting 

Single medical center in Brazil.

Back to Article Outline

Participants 

A total of 640 healthy term newborns.

Back to Article Outline

Intervention 

Infants at 12 to 72 hours of life were assigned to receive an intramuscular injection of hepatitis B vaccine in the right thigh according to 4 analgesia groups: no analgesia (routine); oral 25% dextrose treatment, given 2 minutes before the injection; skin-to-skin contact, initiated 2 minutes before the injection and persisting throughout the procedure; and a combination of the oral dextrose treatment and skin-to-skin contact strategies.

Back to Article Outline

Outcomes 

Neonatal Facial Coding System and Neonatal Infant Pain Scale scores were evaluated before the procedure, during thigh cleansing, during the injection, and 2 minutes after the injection. Premature Infant Pain Profile scores also were assessed for all infants. Pain scores were compared among the 4 groups.

Back to Article Outline

Main Results 

Oral 25% dextrose treatment reduced the duration of procedural pain in the studied population. Skin-to-skin contact decreased injection pain and duration. The combination of the 2 analgesic measures was more effective than either measure separately for term newborns.

Back to Article Outline

Conclusions 

Nonpharmacologic analgesic measures were effective for the treatment of procedural pain in term infants. The combination of oral 25% dextrose treatment and skin-to-skin contact acted synergistically to decrease acute pain in healthy neonates.

Back to Article Outline

Commentary 

Demonstrating the efficacy of nonpharmacologic strategies to minimize neonatal procedural pain through a randomized, controlled, clinical trial is an admirable goal. Such evidence is needed by pediatricians who wish to minimize the risks of pharmacologic analgesic agents while following the recommended guidelines on minimizing neonatal pain. Unfortunately, because of some concerns with the method, this trial does little to advance the extant literature demonstrating the efficacy of the tested nonpharmacologic agents. First, it is unclear whether the investigators established beforehand what outcomes would be deemed significant, calling into question the validity of the conclusions. The selective reporting of analysis across the 3 tools used in the study heightens this concern. The authors also did not comment on the (possibly significant) difference in baseline scores in the 2 tools from which they reported data at that time point. The higher mean score in the standard care arm implies that either those neonates truly were more uncomfortable at baseline, which should have been controlled for and raises concerns for the effectiveness of the randomization process, or that the observers were not effectively blinded. Finally, the care given to the standard care group in this study does not represent standard of care in most institutions; that is, neonates who are rooming-in are typically cuddled by a caregiver after painful stimuli. Particularly when evaluating skin-to-skin care, it would be more applicable to establish a realistic control arm. This critique is not meant to denigrate the authors' appreciated attempt to add further to our understanding on this topic, but merely to indicate that, as always, further study is needed.