More Pain

One comment on a previous post was about pain control for, among other things, nasogastric tube insertion. Lo and behold a new publication (Ravishankar A, Thawani R, Dewan P, Das S, Kashyap A, Batra P, Faridi MMA: Oral dextrose for analgesia in neonates during nasogastric tube insertion: A randomised controlled trial. Journal of Paediatrics and Child Health 2013). Oral glucose solution reduced the pain responses to nasogastric tube insertion.

In this randomized trial 25% dextrose reduced PIPP scores compared to 10% dextrose when given prior to nasogastric tube insertion. The PIPP scores were still quite high, with a median of 10, despite the 25% dextrose, (12 in the placebo and 10% dextrose groups) showing that it wasn’t all that effective. A previous study, using the facial coding system NCFS showed that sucrose was effective. The authors of the new study suggest that glucose might be a better choice for low income countries as 24% sucrose solution is not readily available. I don’t really understand this, you don’t need to buy some commercial preparation, you can make your own with boiled water and table sugar. I think that should be available everywhere. We used to do that in one of my previous hospitals before the commercial preparation became available, it works, it’s dirt cheap and it’s just as safe.

The osmolarity of 24% sucrose is also about half of 25% dextrose. Whether that matters or not I am not sure, another comment on a previous post asked about whether the high osmolarity of concentrated sucrose solutions is an issue. I replied that it didn’t seem to be, the small volumes given in the mouth will be diluted by saliva before being swallowed and then further diluted with gastric secretions, and although there are some reports of high osmolarity solutions, and high osmolarity milk (like the older formulation of nutramigen) leading to an increase in NEC, there is no evidence of an increase in NEC in the trials of sucrose solutions.

Another study, (Lago P, Garetti E, Boccuzzo G, et al: Procedural pain in neonates: the state of the art in the implementation of national guidelines in Italy. Pediatric Anesthesia 2013, 23(5):407-414.) from the Italian neonatal pain group showed that, although most NICUs knew the guidelines for pain control, actual usage, as determined by their response to a questionnaire was very poor. Seriously painful events were often not treated ‘Pain medication was routinely administered at 34.3% NICUs for tracheal intubation … 71.4% for chest tube insertion, 33.0% for lumbar puncture, and 64.0% for postoperative pain. I find it surprising and disturbing that a third of postop babies are not getting pain medications.

Celeste Johnston and a group of people interested in neonatal pain (including yours truly) published an article a couple of years back based on direct observation in several Canadian NICUs. The results were just as bad. Lumbar Punctures and even chest tubes without analgesia.

We really must do better.

About keithbarrington

I am a neonatologist and clinical researcher at Sainte Justine University Health Center in Montréal
This entry was posted in Neonatal Research and tagged , , . Bookmark the permalink.

4 Responses to More Pain

  1. woodra01 says:

    In the NICU, my baby performed many tricks. She would pose in the downward facing dog position, crawl across her isolette while dragging her head, and pull out her g tube. While she was on CPAP, she had an OG tube. Later, she had an NG tube. She was incredibly sneaky and mastered pulling out both types. One day, I was present when it was reinserted three times without anesthesia (I didn’t know any better). I think about this regularly because feeding is a struggle for us (sensitive gag reflex and anxiety as the mouth is approached). I would like to see a study that investigates the correlation between the use of anesthesia for OG/NG tube insertion and the rate of feeding disorders later.

    • That is a great idea for a study, I think it is entirely possible that all of the unpleasant invasions into a babies mouth and throat are part of the reasons for the oral aversion that many develop.
      Use of analgesia for OG or NG tube insertions is quite rare, so it could make a big difference to good development of normal feeding responses to do so regularly.

  2. Alyssa Kent says:

    just catching up. Thanks for following up with this post. Similarly to woodra01, in some ways I felt that the many many NG/OG placements that happened in weeks 33-41 were mare damaging from on oral defensiveness perspective than my daughters lengthy intubation.

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