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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 5  |  Issue : 1  |  Page : 46-50

Evaluation of breastfeeding and 30% glucose solution as analgesic measures in indigenous African term neonates


1 Department of Pediatrics, Pediatrics and Sub-specialities Unit, Yaounde Gynaeco-Obstetric and Pediatric Hospital, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
2 Department of Pediatrics, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon

Date of Web Publication6-Jan-2016

Correspondence Address:
Andreas Chiabi
Pediatrics and Sub-specialities Unit, Yaoundé Gynaeco-Obstetric and Pediatric Hospital, P.O. Box 4262, Yaounde
Cameroon
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4847.173269

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  Abstract 

Objectives: To compare the analgesic effect of breastfeeding and 30% glucose on pain induced in term newborns during a single painful procedure. Study Design and Setting: We conducted an open design trial, from January to October 2013, at the maternity of the Yaounde Gynaeco-Obstetric and Paediatric Hospital. Patients and Methods: We included healthy term newborns of at least 24 h of life; a heel prick was done, using a 23-gauge syringe, after an analgesic with breastfeeding or 30% glucose. The newborns were divided into two groups by drawing of lots. The pain was evaluated using the Neonatal Infant Pain Scale. Results: Fifty newborns were recruited per group. The median (interquartile range [IQR]) pain scores, during pricking, were 2 (1.5–3.5) and 3 (2.5–4.5), in the groups of breastfeeding and 30% glucose respectively, with a significant statistical difference (P < 0.001). We found a median (IQR) pain score of 3 (2.5–4), in newborns weighing between 2500 and 3000 g, against 2 (1–3) in those weighing above 3000 g with a significant statistical difference (P = 0.02). Conclusion: The analgesic effect of breastfeeding is greater than that of 30% glucose solution, in newborns undergoing a single painful procedure. Term newborns weighing between 2500 and 3000 g express pain more than those weighing more than 3000 g.

Keywords: 30% glucose, acute pain, breastfeeding, newborn


How to cite this article:
Chiabi A, Eloundou EO, Mah E, Nguefack S, Mekone IN, Mbonda E. Evaluation of breastfeeding and 30% glucose solution as analgesic measures in indigenous African term neonates. J Clin Neonatol 2016;5:46-50

How to cite this URL:
Chiabi A, Eloundou EO, Mah E, Nguefack S, Mekone IN, Mbonda E. Evaluation of breastfeeding and 30% glucose solution as analgesic measures in indigenous African term neonates. J Clin Neonatol [serial online] 2016 [cited 2019 Dec 15];5:46-50. Available from: http://www.jcnonweb.com/text.asp?2016/5/1/46/173269


  Introduction Top


Several painful procedures are inflicted on neonates during the care that they receive in hospital settings, during drug administration, or during blood sample collection for biologic investigations and detection of certain pathologies.[1] Lack of prevention or management of pain will lead to an increase secretion of stress hormones that will lead to increase morbidity.[2] It is clearly stated that the repetition of painful experiences can lead to future hyperalgesia, responsible for behavioral and social adaptation disorders in children who received painful procedures without analgesia in the neonatal period.[3],[4]

Management of acute neonatal pain requires the use of an evaluation scale which determines the intensity of pain and resort to pharmacologic or nonpharmacologic means of preventing or reducing pain.[5] The effectiveness of 30% glucose in reducing pain scores during heel lances in healthy term neonates has been well demonstrated.[6] Breastfeeding, which is nonpharmacologic, remains a simple and accessible method to reduce pain in the neonate sustaining a single painful stimulus; this analgesic effect was found to be effective and even better than that obtained from a sugar solution like a 30% glucose solution.[7],[8],[9]

In Cameroon, only one randomized, double-blind study comparing 30% glucose solution and placebo has been done, and it was noted that the 30% glucose solution only had an analgesic effect during intravenous punctures and no effect during intramuscular injections.[10]

No study has been done to evaluate the analgesic effect of breastfeeding, in term neonates in our setting. The main objective of our study was to comparatively evaluate the analgesic effect of breastfeeding and 30% glucose solution on induced pain during a single painful stimulus in term healthy Cameroonian neonates.


  Patients and Methods Top


We did a randomized, open clinical trial at the maternity of the Yaoundé Gynaeco-Obstetric and Paediatric Hospital (YGOPH) from January 02 to October 31, 2013.

Procedure

We included in the study healthy term neonates of at least 24 h life. They first had a complete physical examination, and then we did a heel prick on the latero-external or the postero-medial surface using a 23 gauge needle. Breastfeeding or 30% glucose solution was then given. The newborns were divided into the two groups by drawing of lots. We excluded from the study neonates whose mothers took neuroleptic medications at the end of the pregnancy; those whose Apgar score was <7 at the 5th min; those born from an instrumental delivery; those with an affection which could cause pain other than that caused by the heel lancing; those on strict artificial feeding; those with risks of neonatal infection or with a confirmed neonatal infection; and finally those whose parents refused to take part in the study.

For neonates in the breastfeeding group, their mothers were placed in a calm room and the neonates placed on the breast after a period of about 30 min without feeding; the neonates were held in the arms of their mothers, and the heel prick was done 2 min later, just time sufficient for a good latch and sucking before performing the heel prick. The investigators also verified the elements testifying a good position and attachment on the breast as recommended by the World Health Organization.[11] For neonates in the 30% glucose solution group, we used the protocol proposed in the neonatology unit of Anger's University Teaching Hospital, in France;[12] these neonates received, two doses of 30% glucose solution in a 2 min interval on the anterior surface of the tongue: Taking into account the weight of the neonate during the realization of the trial - 1 ml for those who weighted between 2500 and 3000 g and 2 ml for those who weighed more than 3000 g. The two doses were administered 2 min before doing the heel prick. Newborns weighing between 2.5 and 3 kg received 2 ml of the solution and those weighing more than 3 kg received 4 ml. The heel pricks were performed by five different health personnel as part of the research team and previously trained. They professionally did the heel pricks to determine the blood sugar.

We took the maternal and neonatal characteristics. The Neonatal Infant Pain scale (NIPS) [Table 1] was used to evaluate pain by the same observer trained to use this scale; at the baseline state, at the impact of the needle and 2 min after the capillary prick. The advantages of this scale are that: It is practical, and is only made up of behavioral and physiologic items which can be scored in <30 s and has a wide flexibility in scoring acute neonatal pain. Data obtained was noted on an individual and anonymous questionnaire.
Table 1: Neonatal Infant Pain Scale

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Calculating sample size

We calculated the sample size using Zhong's formula in randomized clinical trials.[13] This permitted us to determine that we had to include 44 neonates per group to detect a 2 point difference on the NIPS with a power of 80% and a level of significance at 5%. We decided to include 50 neonates per group to eliminate errors related to the observer.

Ethical consideration

We obtained ethical clearance from the Institutional Ethical Committee of Research in human health of the YGOPH before the onset of the study. An informed consent was obtained from the parents of the neonates before the enrollment of their children.

Data analysis

Data were collected and analyzed using the software Epi Info™ version 7.1.1.14 (centers for disease control and prevention (CDC) in Atlanta, Georgia (USA)) and OpenStat (Developed by Bill Miller of Iowa State University). Statistical analysis of pain scores was done using nonparametric tests; Mann–Whitney U-test and Kruskal–Wallis H-test, and the level of significance was leveled at 5% (P < 0.05).


  Results Top


We enrolled 100 term neonates who were randomly and consecutively marked on one of the groups in the clinical trial; 50 neonates per group.

Characteristics of the study population

The mean maternal age enrolled in the study was 27.9 (6.32) years in the breastfeeding group and 26.9 (6.37) years in the 30% glucose solution group with extremes in the general population being 25 and 43 years. The median (interquartile range [IQR]) parity was 3 (1–4) in the breastfeeding group against 2 (1–4) in the other group. Primiparas were the most represented with a total of 28 mothers. More than half of the mothers recruited, 52 had a secondary level of education [Table 2].
Table 2: Characteristics of the study population

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The sex ratio was 0.9, and we had about 80 neonates with birth weights >3000 g. The mean (standard deviation [SD]) birth weight was 3316 (394.1) g, in the 30% glucose solution group against 3234 (282.2) g in the other group. The mean gestational age was 39.3 (1.2) WA in the general population. Four neonates were born through a cesarean section. The neonates recruited had a good adaptation to the extrauterine environment with a mean Apgar at the 5th min of 10/10 in both groups. The mean (SD) postnatal age in the clinical trial was 54.7 (11.6) h. The mean time limit between feedings was 92.6 min.

Pain evaluation

The neonates in the breastfeeding group had a basal median (IQR) score for the pain of 0 (0.5–0.5) against 0 (0–0) in the 30% glucose solution group without any statistical significance (U-statistic: 1275; P = 0.43). We had a median (IQR) score of pain at impact with the needle of 3 (2.5–4.5) in the 30% glucose group against 2 (1.5–3.5) in the breastfeed group [Figure 1]; this difference was statistically significant (U-statistic: 1815; P < 0.001). The median score of pain in the 30% glucose group was 1.5 times higher than that in the breastfeeding group. The median (IQR) pain score 2 min after the heel lancing was 0 (0–0) in the breastfeeding group against 1 (0.5–1.5) in the 30% glucose solution group without any statistically significant difference (U-statistic: 1808; P = 0.87).
Figure 1: Pain score at the impact with the needle according to type of analgesia

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Evaluation of factors influencing the pain scores

We searched for neonatal and maternal factors which could influence the pain score at the moment of impact with the needle, independent of the analgesic method used, since both of them have been shown to be effective in the reduction of pain scores.

Neonatal factors

The mean pain score in the female neonate was 2.35 against 2.44 in boys; slightly lower by 0.1 point. We had a median (IQR) pain score of 3 (2, 5–4) and 2 (1–3) respectively in neonates with birth weights between 2500 and 3000 g and those with birth weights >3000 g [Figure 2] (U-statistic: 1036; P = 0.02). The postnatal age had no impact on the pain score during the clinical trial. Neonates with a time limit between feedings exceeding 165 min, had a higher median pain score without any statistically significant difference compared with those who had a time limit less than the above limit (H-statistic: 0.95, P = 0.64) [Figure 3].
Figure 2: Distribution of pain scores at the impact with needle according to weight (in grams)

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Figure 3: Distribution of pain Scores at the impact with needle according to time-.limit between feedings (in minutes)

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Maternal factors

Newborns of mothers aged over 40 years had the highest median (IQR) pain score, 3.5 (2.5–3.5), without any statistically significant difference (H-statistics: 6.67, P = 0.28) compared to other groups. The highest median (IQR) pain score was found in newborns of mothers with parity 6, 3.6 (3.5–4.5), but no statistically significant difference noted with other groups (H-statistics: 9.15, P = 0.127).


  Discussion Top


The analgesic mechanisms of breastfeeding and glucose solutions are complex. The various components of breastfeeding, such as the taste of breast milk, suction, touch, smell or maternal warmth may have a role. However, a nonopioid mechanism is not excluded.[3] The analgesic effect of the 30% glucose is very likely related to the release of endogenous opioids with direct control over the pathways of nociception, and oro-gustatory stimulation of sweet taste receptors which are located on the tip of the tongue, and this entails the release of endogenous morphine.[14] Comparing the two methods in our setting appeared important because 30 % glucose solution is not always available.

At baseline, we had a median pain score of 0 in the two groups, reflecting a lack of response which could influence the assessment of pain at the time of impact with the needle. On the impact of the needle, we obtained median pain scores of 2 and 3, respectively in breastfeeding and 30% glucose groups, reflecting a sure analgesic effect of these two analgesic methods, but more marked in those in breastfeeding group. In fact, in the absence of analgesic treatment Osinaike et al., obtained a median pain score of 4, using the same scale, in newborns undergoing peripheral venepuncture.[15] The median pain score was 1.5 times higher in the 30% glucose solution group compared to the breastfeeding group. The significant difference noted reflects the analgesic superiority of breastfeeding on glucose 30% in case of heel prick in term neonates as found by Codipietro et al.[16] Carbajal et al. also demonstrated the analgesic efficacy of the two methods by having a median pain score 3 times higher in the 30% glucose solution group compared to the breastfeeding group, but newborns in the 30% glucose group received the solution associated with the sucking of a pacifier.[8] In addition, it has been shown that nonnutritive sucking alone provides some analgesic effect in acute pain in term neonates.[17]

The meta-analysis of Shah et al., on 10 studies evaluating the analgesic efficacy of breastfeeding in the newborn ultimately found a similar overall efficacy with 30% glucose solution.[7] Gray et al. have demonstrated the benefits of breastfeeding beyond the analgesic effect compared to 30% glucose solution. They found a reduction of grimaces and crying time, and a slight increase of heart rate during single painful procedures among breastfed neonates as compared to those on 30% glucose, reflecting less stress with breastfeeding.[18] Analysis of pain scores obtained 2 min after lancing shows the analgesic efficacy of both methods on the time perception of pain and the return to calm, even though with a slight superiority of breastfeeding.

Newborns weighing between 2500 and 3000 g had a median pain score 1.5 times higher compared to those with a higher birth weight. The significant statistical difference of this fact highlights a greater expression of pain in them. This increased expression of pain could be due to the variation of mechanoreceptors whose density and maturation appear to increase with gestational age and weight.[19] This could also be due to the dose of 30%glucose solution administered since all newborns <3000 g who were allocated to the 30% glucose solution group received 1 ml of the solution (0.3 g). Haouari et al. had demonstrated increased analgesic effect of sweet solutions depending on the concentration and amount received.[20] This suggests an increase in the amount of 30% glucose solution during single painful procedures, from 0.3 (1 ml) to 0.6 g (2 ml) per dose, such as in those weighing >3000 g. We also advocate the preferential use in newborn infants weighing between 2500 and 3000 g of the analgesic method that showed the greatest efficacy, which is breastfeeding. We did not find an impact of fasting on pain scores. No maternal factor had an influence on the painful expression. In other studies, maternal age and parity were considered only as demographics characteristics.[8],[15],[16]

However, a limitation of our study is that it was not possible to have video recording equipment at the completion of the painful procedure to assess pain scores by an external observer. In addition, we used a protocol of 30% glucose solution with different doses depending on the weight, which may have influenced the perception and expression of pain in neonates <3000 g.


  Conclusion Top


This open clinical trial showed the effectiveness of breastfeeding and 30% glucose solution on induced pain during a heel capillary prick in term and healthy neonates. We also noted the superiority of the analgesic effect of breastfeeding on 30% glucose solution on the score pain during heel prick. We thus recommend that the medical staff in charge of newborns: Preferentially use breastfeeding in the management of acute pain in term neonates undergoing a single painful procedure, and finally the use of glucose 30% for the reduction of acute pain in term neonates only when breastfeeding is not possible.

Acknowledgments

Many thanks to the nursing staff of the maternity of the YGOPH for their collaboration in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Cruz MD, Fernandes AM, Oliveira CR. Epidemiology of painful procedures performed in neonates: A systematic review of observational studies. Eur J Pain 2015. doi: 10.1002/ejp. 757. [Epub ahead of print].  Back to cited text no. 1
    
2.
Walker SM. Biological and neurodevelopmental implications of neonatal pain. Clin Perinatol 2013;40:471-91.  Back to cited text no. 2
    
3.
Simons SH, Tibboel D. Pain perception development and maturation. Semin Fetal Neonatal Med 2006;11:227-31.  Back to cited text no. 3
    
4.
Fitzgerald M. What do we really know about newborn infant pain? Exp Physiol 2015;100:1451-7. doi: 10.1113/EP085134.  Back to cited text no. 4
    
5.
Stevens BJ, Franck LS. Assessment and management of pain in neonates. Paediatr Drugs 2001;3:539-58.  Back to cited text no. 5
    
6.
Bueno M, Yamada J, Harrison D, Khan S, Ohlsson A, Adams-Webber T, et al. A systematic review and meta-analyses of nonsucrose sweet solutions for pain relief in neonates. Pain Res Manag 2013;18:153-61.  Back to cited text no. 6
    
7.
Shah PS, Herbozo C, Aliwalas LL, Shah VS. Breastfeeding or breast milk for procedural pain in neonates. Cochrane Database Syst Rev 2012;12:CD004950.  Back to cited text no. 7
    
8.
Carbajal R, Veerapen S, Couderc S, Jugie M, Ville Y. Analgesic effect of breast feeding in term neonates: Randomised controlled trial. BMJ 2003;326:13.  Back to cited text no. 8
    
9.
Prevention and management of pain and stress in the neonate. American Academy of Pediatrics. Committee on Fetus and Newborn. Committee on Drugs. Section on Anesthesiology. Section on Surgery. Canadian Paediatric Society. Fetus and Newborn Committee. Pediatrics 2000;105:454-61.  Back to cited text no. 9
    
10.
Talomg TS. Evaluation of 30% glucose solution in the prevention of pain in neonates at the Mother and Child Centre of the Chantal Biya Foundation [Thesis : Med]. Bangangté : Higher Institute of Health Sciences, Bangangté; 2010.  Back to cited text no. 10
    
11.
WHO/UNICEF. Handbook: IMCI integrated management of childhood illness. Geneva, Switzerland: NLM Classification. 2005. p. 116-8.  Back to cited text no. 11
    
12.
Savagner C, Leblanc-Deshayes M, Malbrunot AC, Boithias C, Chabernaud JL, Biran-Mucignat V, et al. Management of pain and discomfort in newborns in the maternity. Mt Pediatrics 2005;8:323-8.  Back to cited text no. 12
    
13.
Zhong B. How to calculate sample size in randomized controlled trial? J Thorac Dis 2009;1:51-4.  Back to cited text no. 13
    
14.
Blass EM, Shide DJ. Some comparisons among the calming and pain-relieving effects of sucrose, glucose, fructose and lactose in infant rats. Chem Senses 1994;19:239-49.  Back to cited text no. 14
    
15.
Osinaike BB, Oyedeji AO, Adeoye OT, Dairo MD, Aderinto DA. Effect of breastfeeding during venepuncture in neonates. Ann Trop Paediatr 2007;27:201-5.  Back to cited text no. 15
    
16.
Codipietro L, Ceccarelli M, Ponzone A. Breastfeeding or oral sucrose solution in term neonates receiving heel lance: A randomized, controlled trial. Pediatrics 2008;122:e716-21.  Back to cited text no. 16
    
17.
Field T, Goldson E. Pacifying effects of nonnutritive sucking on term and preterm neonates during heelstick procedures. Pediatrics 1984;74:1012-5.  Back to cited text no. 17
    
18.
Gray L, Miller LW, Philipp BL, Blass EM. Breastfeeding is analgesic in healthy newborns. Pediatrics 2002;109:590-3.  Back to cited text no. 18
    
19.
Brown L. Physiological responses to cutaneous pain in neonates. Neonatal Netw 1987;5:18-21.  Back to cited text no. 19
    
20.
Haouari N, Wood C, Griffiths G, Levene M. The analgesic effect of sucrose in full term infants: A randomised controlled trial. BMJ 1995;310:1498-500.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]


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