Key messages
- Sucrose, compared to control interventions, probably reduces pain for a single painful event (heel lance).
- There were a few minor immediate adverse events, such as gagging, that resolved without intervention.
- We need studies that assess the effect of repeated sucrose administration on immediate (pain intensity) and long-term (neurodevelopmental) outcomes.
- We need to assess how sucrose affects neonates who are extremely preterm, unstable, or ventilated (or a combination of these factors).
What is sucrose analgesia?
Sucrose (table sugar) is mixed with water in various concentrations (usually 24%) and is given to babies in very small amounts (e.g. a few drops) about two minutes before a painful procedure. Sucrose is also given with other nondrug pain-relieving interventions such as a pacifier (non-nutritive sucking - NNS) or when the baby is receiving skin-to-skin care.
Why is this important for newborn babies who are undergoing heel lance procedures?
Babies who are sick or immature, and require a stay in hospital, have several painful procedures per day and multiple painful procedures throughout the hospital stay; for most babies, the majority of painful procedures are heel lances. If untreated, pain has immediate and long-term consequences that can impact their brain and behavioural development. It is important to minimise the number of painful procedures and the associated pain and suffering.
What did we want to find out?
We wanted to know how well sucrose worked to relieve pain in newborn babies who are having heel lance procedures while they were in hospital. We also wanted to know whether there were any safety concerns about using sucrose to relieve pain from single painful events such as heel lance.
What did we do?
We searched for studies that investigated:
- Sucrose compared to no treatment or standard care;
- Sucrose compared to water, other sweet solutions (e.g. glucose);
- Sucrose compared to another nondrug intervention (e.g. NNS);
- Whether sucrose was effective in decreasing the amount and severity of pain that babies experienced as assessed by baby’s pain responses (e.g. crying, grimacing, heart rate) and by using standardised infant pain scales.
We also wanted to know if sucrose was associated with any unwanted effects in preterm or term babies.
We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods.
What did we find out?
We reviewed 55 studies that included a total of 6273 babies. Twenty-nine studies had full-term babies only, 22 had preterm babies only, and four had both full-term and preterm babies. Heel lance was the painful procedure in 50 studies. Five studies investigated a variety of other minor painful procedures in addition to heel lancing.
Main results
- Sucrose compared to the control treatment probably reduces pain from single heel lances in babies.
- Results are uncertain about the effect of sucrose compared to NNS, breastfeeding, laser acupuncture, and facilitated tucking, in reducing pain scores.
- Results are uncertain about the effect of sucrose + NNS compared to NNS, in reducing pain.
- Sucrose does not seem to reduce pain from single heel lances compared to glucose, expressed breast milk, and skin-to-skin care.
- Reported adverse events were minor and resolved without any intervention.
What are the limitations of the evidence?
We have moderate-certainty evidence that sucrose likely reduces pain from heel lance.
How up-to-date is this evidence?
This evidence is up-to-date as of February 2022.
Study funding sources
We did not identify any studies that received funding from industry.
Sucrose compared to control probably results in a reduction of PIPP scores 30 and 60 seconds after single heel lances (moderate-certainty evidence). Evidence is very uncertain about the effect of sucrose compared to NNS, breastfeeding, laser acupuncture, facilitated tucking, and the effect of sucrose + NNS compared to NNS in reducing pain. Sucrose compared to glucose, expressed breast milk, and skin-to-skin care shows little to no difference in pain scores. Sucrose combined with other nonpharmacologic interventions should be used with caution, given the uncertainty of evidence.
Sucrose has been examined for calming and pain-relieving effects in neonates for invasive procedures such as heel lance.
To assess the effectiveness of sucrose for relieving pain from heel lance in neonates in terms of immediate and long-term outcomes
We searched (February 2022): CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and three trial registries.
We included randomised controlled trials where term and/or preterm neonates received sucrose for heel lances. Comparison treatments included water/placebo/no intervention, non-nutritive sucking (NNS), glucose, breastfeeding, breast milk, music, acupuncture, facilitated tucking, and skin-to-skin care.
We used standard Cochrane methods. We reported mean differences (MD) with 95% confidence intervals (CI) using the fixed-effect model for continuous outcome measures. We assessed heterogeneity by the I2 test. We used GRADE to assess certainty of evidence.
We included 55 trials (6273 infants): 29 included term neonates, 22 included preterm neonates, and four included both. Heel lance was investigated in 50 trials; 15 investigated other minor painful procedures in addition to lancing.
Sucrose vs control
The evidence suggests that sucrose probably results in a reduction in PIPP scores compared to the control group at 30 seconds (MD -1.74 (95% CI -2.11 to -1.37); I2 = 62%; moderate-certainty evidence) and 60 seconds after lancing (MD -2.14, 95% CI -3.34 to -0.94; I2 = 0%; moderate-certainty evidence).
The evidence is very uncertain about the effects of sucrose on DAN scores compared to water at 30 seconds after lancing (MD -1.90, 95% CI -8.58 to 4.78; heterogeneity not applicable (N/A); very low-certainty evidence).
The evidence suggests that sucrose probably results in a reduction in NIPS scores compared to water immediately after lancing (MD -2.00, 95% CI -2.42 to -1.58; heterogeneity N/A; moderate-certainty evidence).
Sucrose vs NNS
The evidence is very uncertain about the effect of sucrose on PIPP scores compared to NNS during the recovery period after lancing (MD 0.60, 95% CI -0.30 to 1.50; heterogeneity not applicable; very low-certainty evidence) and on DAN scores at 30 seconds after lancing (MD -1.20, 95% CI -7.87 to 5.47; heterogeneity N/A; very low-certainty evidence).
Sucrose + NNS vs NNS
The evidence is very uncertain about the effect of sucrose + NNS on PIPP scores compared to NNS during lancing (MD -4.90, 95% CI -5.73 to -4.07; heterogeneity not applicable; very low-certainty evidence) and during recovery after lancing (MD -3.80, 95% CI -4.47 to -3.13; heterogeneity N/A; very low-certainty evidence).
The evidence is very uncertain about the effects of sucrose + NNS on NFCS scores compared to water + NNS during lancing (MD -0.60, 95% CI -1.47 to 0.27; heterogeneity N/A; very low-certainty evidence).
Sucrose vs glucose
The evidence suggests that sucrose results in little to no difference in PIPP scores compared to glucose at 30 seconds (MD 0.26, 95% CI -0.70 to 1.22; heterogeneity not applicable; low-certainty evidence) and 60 seconds after lancing (MD -0.02, 95% CI -0.79 to 0.75; heterogeneity N/A; low-certainty evidence).
Sucrose vs breastfeeding
The evidence is very uncertain about the effect of sucrose on PIPP scores compared to breastfeeding at 30 seconds after lancing (MD -0.70, 95% CI -0.49 to 1.88; I2 = 94%; very low-certainty evidence).
The evidence is very uncertain about the effect of sucrose on COMFORTneo scores compared to breastfeeding after lancing (MD -2.60, 95% CI -3.06 to -2.14; heterogeneity N/A; very low-certainty evidence).
Sucrose vs expressed breast milk
The evidence suggests that sucrose may result in little to no difference in PIPP-R scores compared to expressed breast milk during (MD 0.3, 95% CI -0.24 to 0.84; heterogeneity not applicable; low-certainty evidence) and at 30 seconds after lancing (MD 0.3, 95% CI -0.11 to 0.71; heterogeneity N/A; low-certainty evidence).
The evidence suggests that sucrose probably may result in slightly increased PIPP-R scores compared to expressed breast milk 60 seconds after lancing (MD 1.10, 95% CI 0.34 to 1.86; heterogeneity N/A; low-certainty evidence).
The evidence is very uncertain about the effect of sucrose on DAN scores compared to expressed breast milk 30 seconds after lancing (MD -1.80, 95% CI -8.47 to 4.87; heterogeneity N/A; very low-certainty evidence).
Sucrose vs laser acupuncture
There was no difference in PIPP-R scores between sucrose and music groups; however, data were reported as medians and IQRs.
The evidence is very uncertain about the effect of sucrose on NIPS scores compared to laser acupuncture during lancing (MD -0.86, 95% CI -1.43 to -0.29; heterogeneity N/A; very low-certainty evidence).
Sucrose vs facilitated tucking
The evidence is very uncertain about the effect of sucrose on total BPSN scores compared to facilitated tucking during lancing (MD -2.27, 95% CI -4.66 to 0.12; heterogeneity N/A; very low-certainty evidence) and during recovery after lancing (MD -0.31, 95% CI -1.72 to 1.10; heterogeneity N/A; very low-certainty evidence).
Sucrose vs skin-to-skin + water (repeated lancing)
The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin-to-skin + water at 30 seconds after 1st (MD 0.13, 95% CI -0.70 to 0.96); 2nd (MD -0.56, 95% CI -1.57 to 0.45); or 3rd lancing (MD-0.15, 95% CI -1.26 to 0.96); heterogeneity N/A, low-certainty evidence for all comparisons.
The evidence suggests that sucrose results in little to no difference in PIPP scores compared to skin-to-skin + water at 60 seconds after 1st (MD –0.61, 95% CI -1.55 to 0.33); 2nd (MD -0.12, 95% CI -0.99 to 0.75); or 3rd lancing (MD-0.40, 95% CI -1.48 to 0.68); heterogeneity N/A, low-certainty evidence for all comparisons.
Minor adverse events required no intervention.