The truth about pediatric analgesia – Justin Morgenstern
Treating pain is important. Treating pain in a vulnerable population like infants, who cannot speak for themselves, is especially important. Unfortunately, there is a great deal of evidence, from many clinical settings, that suggests that we don’t do a great job treating pediatric pain.
Recognising this problem, and based on a large number of randomised controlled trials, many experts recommended the use of sucrose to manage infants’ pain. I question this approach, and suggest we are safer to assume that sucrose is not a pain medication. Unfortunately, we can’t measure pain in infants. The experience is entirely subjective. However, sucrose has been studied in populations who can report their pain (older children and adults) and does not work. Sucrose changes behavioural scores in infants, but those scores do not measure pain. Even if they did, observation is inaccurate for estimating pain in older populations who are able to report pain scores, so we should be skeptical of their accuracy in infants. Furthermore, in brain imaging studies, despite looking calmer, infants‚ brains still react as if they are in pain when sucrose is given.
I think the safest approach is to assume that sucrose is not a pain medication, and focus on other analgesic options (with proven effect in patient populations that can report their pain). Instead of relying on sucrose, I offer my top five tips for pediatric pain control.
- Limit painful procedures whenever possible. (Think carefully about whether tests will actually change management. Use oral meds instead of IM or IV. Group painful procedures together.)
- Think topical. EMLA is a proven option, but amethocaine works faster, and therefore might be a better option.
- Consider using nerve blocks.
- Remember the intranasal route. Fentanyl, ketamine, and midazolam are all excellent agents that can be used intranasally to help with pediatric pain and anxiety.
- Think about distress, not just pain.
Justin Morgenstern (@First10EM) a Canadian emergency doctor currently lost in Taranaki, New Zealand. A skeptic at heart, who can’t stop asking questions, and therefore spends too much time lost in the medical literature. Attempts to clear mind of medicine by wandering in nature with a camera. First10EM is his primary FOAM project.
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Is it possible to get the link to the brain imaging studies looking at sucrose? Would be very interested to read more!
From Justin: the three main references are:
Slater R, Cantarella A, Franck L, Meek J, Fitzgerald M. How well do clinical pain assessment tools reflect pain in infants? PLoS medicine. 2008; 5(6):e129.
Slater R, Cornelissen L, Fabrizi L. Oral sucrose as an analgesic drug for procedural pain in newborn infants: a randomised controlled trial. Lancet (London, England). 2010; 376(9748):1225-32. [pubmed]
Rioualen S, Durier V, Hervé D, Misery L, Sizun J, Roué JM. Cortical Pain Response of Newborn Infants to Venepuncture The Clinical Journal of Pain. 2018;
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