Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years
Extensive evidence exists showing analgesic effects of sweet solutions for newborns and infants. It is less certain if the same analgesic effects exist for children one year to 16 years of age. This is an updated version of the original Cochrane review published in Issue 10, 2011 (Harrison 2011) titled Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years.
To determine the efficacy of sweet tasting solutions or substances for reducing needle‐related procedural pain in children beyond one year of age.
Searches were run to the end of June 2014. We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Cochrane Methodology Register, Health Technology Assessment, the NHS Economic Evaluation Database, MEDLINE, EMBASE, PsycINFO, and ACP Journal Club (all via OvidSP), and CINAH (via EBSCOhost). We applied no language restrictions.
Published or unpublished randomised controlled trials (RCT) in which children aged one year to 16 years, received a sweet tasting solution or substance for needle‐related procedural pain. Control conditions included water, non‐sweet tasting substances, pacifier, distraction, positioning/containment, breastfeeding, or no treatment.
Data collection and analysis
Outcome measures included crying duration, composite pain scores, physiological or behavioral pain indicators, self‐report of pain or parental or healthcare professional‐report of the child's pain. We reported mean differences (MD), weighted mean difference (WMD), or standardized mean difference (SMD) with 95% confidence intervals (CI) using fixed‐effect or random‐effects models as appropriate for continuous outcome measures. We reported risk ratio (RR), risk difference (RD), and the number needed to treat to benefit (NNTB) for dichotomous outcomes. We used the I2 statistic to assess between‐study heterogeneity.
We included one unpublished and seven published studies (total of 808 participants); four more studies and 478 more participants than the 2011 review. Six trials included young children aged one to four years receiving sucrose or candy lollypops for immunisation pain compared with water or no treatment. Usual care included topical anaesthetics, upright parental holding, and distraction. All studies were well designed blinded RCTs, however, five of the six studies had a high risk of bias based on small sample sizes.
Two studies included school‐aged children receiving sweet or unsweetened chewing gum before, or before and during, immunisation and blood collection. Both studies, conducted by the same author, had a high risk of bias based on small sample sizes.
Results for the toddlers/pre‐school children were conflicting. Duration of cry, using a random‐effects model, was not significantly reduced by sweet taste (six trials, 520 children, WMD ‐15 seconds, 95% CI ‐54 to 24, I2 = 94%).
Composite pain score at time of first needle was reported in four studies (n = 121 children). The scores were not significantly different between the sucrose and control group (SMD ‐0.26, 95% CI ‐1.27 to 0.75, I2 = 86%).
A Children's Hospital of Eastern Ontario Pain Scale score > 4 was significantly less common in the sucrose group compared to the control group in one study (n = 472, RR 0.55, 95% CI 0.45 to 0.67; RD ‐0.29, 95% CI ‐0.37 to ‐0.20; NNTB 3, 95% CI 3 to 5; tests for heterogeneity not applicable.
For school‐aged children, chewing sweet gum before needle‐related painful procedures (two studies, n = 111 children) or during the procedures (two studies, n = 103 children) did not significantly reduce pain scores. A comparison of the Faces Pain Scale scores in children chewing sweet gum before the procedures compared with scores of children chewing unsweetened gum revealed a WMD of ‐0.15 (95% CI ‐0.61 to 0.30). Similar results were found when comparing the chewing of sweet gum with unsweetened gum during the procedure (WMD 0.23, 95% CI ‐0.28 to 0.74). The Colored Analogue Scale for children chewing sweet gum compared to unsweetened gum before the procedure was not significantly different (WMD 0.24 (‐0.69 to 1.18)) nor was it different when children chewed the gum during the procedure (WMD 0.86 (95% CI ‐0.12 to 1.83)). There was no heterogeneity for any of these analyses in school‐aged children (I2 = 0%).
Based on the eight studies included in this systematic review update, two of which were subgroups of small numbers of eligible toddlers from larger studies, and three of which were pilot RCTs with small numbers of participants, there is insufficient evidence of the analgesic effects of sweet tasting solutions or substances during acutely painful procedures in young children between one and four years of age. Further rigorously conducted, adequately powered RCTs are warranted in this population. Based on the two studies by the same author, there was no evidence of analgesic effects of sweet taste in school‐aged children. As there are other effective evidence‐based strategies available to use in this age group, further trials are not warranted.
Despite the addition of four studies in this review, conclusions have not changed since the last version of the review.
Denise Harrison, Janet Yamada, Thomasin Adams‐Webber, Arne Ohlsson, Joseph Beyene, Bonnie Stevens
Plain language summary
Sweet taste to ease injection needle pain in children aged one to 16 years
This is an updated version of the original Cochrane review published in Issue 10, 2011: Sweet tasting solutions for reduction of needle‐related procedural pain in children aged one to 16 years. We re‐ran the search in October 2014.
Review question: Do sweet tasting solutions reduce pain during needles in children aged from one to 16 years, compared to no treatment, water, other non‐sweet solutions, or other interventions such as non‐nutritive sucking (babies) or sweet foods or chewing gum (children), topical anaesthetics, music, and distraction?
Background: Small amounts of sweet tasting sugar solutions given orally to babies before and during painful needles significantly reduces distress. However it was not known if the same pain‐reducing effects of sweet solutions occurred in children older than one year of age. We therefore examined studies looking at pain‐reducing effects of sweet solutions such as sucrose or glucose for painful needle procedures in children aged one to 16 years.
Search date: We searched the literature for published and unpublished studies up to October 2014.
Study characteristics: We found six studies focused on young children aged one to four years; two of these studies were included in the original review and four were new studies. The two studies included in the original review used a low concentration of sucrose, just 12%, which is not considered sweet enough for the pain reducing effects. Three of the four new studies were small pilot studies, conducted to inform full trials, and only one study of sweet solutions in young children included large numbers of children. When we compared results of all six studies, only two showed that sugar water (sucrose) reduced pain during injections. However, the four studies that showed no effect all included small numbers of children, therefore they were not considered large enough to detect significant differences in pain. Further well conducted trials with large enough numbers of young children are needed to work out if sweet taste effectively reduces their pain and distress during needles.
For older school‐aged children, there were two studies published by the same author, both of which were included in the original review. Neither study showed that sweet taste helped to reduce pain. As other studies show that strategies such as distraction and topical anaesthetics can effectively reduce needle pain in school‐aged children, further studies of sweet taste for pain management in school‐aged children are not warranted.
Study funding sources:
Of the six studies including young children, two did not acknowledge receipt of research funding. For the remaining four: a state‐wide nursing fund supported two of the pilot studies, an internal research institute provided support for the remaining pilot study and another study was supported in part by a Maternal and Child Health grant.
The two studies including school‐aged children, conducted by the same author, were supported by a grant from the Canadian Institutes of Health Research.
Denise Harrison, Janet Yamada, Thomasin Adams‐Webber, Arne Ohlsson, Joseph Beyene, Bonnie Stevens
Implications for practice
For toddlers and pre‐school children: The conflicting evidence from only six studies which included young children, two of which were small sub‐groups of children, and three of which were small pilot RCTs, is currently insufficient to recommend sucrose as a pain‐management strategy in young children beyond 12 months of age. Further evidence, including effectiveness of dosing in aliquots prior to and during the procedure and comparisons of different concentrations of sweet solutions is required before evidence‐based recommendations for practice can be made.
For school‐aged children: Based on a lack of difference in self‐reported pain scores between children randomised to sweet taste condition and unsweetened taste condition during needle‐related procedures, there is no evidence to support analgesic efficacy of sweet taste during needle‐related procedures. This strategy should not, therefore, be considered in this population.
Implications for research
General: There is sufficient evidence from large numbers of RCTs of the analgesic effects of sucrose or glucose for newborn infants, and infants up to one year of age. However, there remains a state of equipoise relating to analgesic effects of sweet taste during needle‐related and other procedures in young children.
For young children: Further RCTs in this population are warranted. When planning further studies, particular attention should be paid relating to the following points:
- Conduct a priori power calculations to ensure RCTs are adequately powered.
- Ensure concealment of allocation and blinding of outcome assessors to interventions.
- Implement current evidence‐based distraction techniques (Chambers 2009) as well as parental upright holding if possible, and comforting, as standard of care.
- Particularly for venipuncture studies, topical anaesthetics should be considered as standard of care.
- Standardize control interventions; e.g. upright parental holding, distraction techniques used.
- Use sufficient concentration and dose of sweet solution; i.e. ≥ 20% glucose or sucrose, administered one minute before procedures in this age group, and repeated throughout the duration of procedures.
- Use recommended, comparable, reliable, and valid pain outcome measures.
For school‐aged children: Despite the small number of studies examining analgesic efficacy of sweet taste in school‐aged children, the available evidence from the two studies included in this review, as well as three studies of sweet taste during CPT (Mennella 2010; Miller 1994; Pepino 2005), suggest that this intervention is not of sufficient benefit to recommend at this time. Further studies of sweet tasting solutions, substances, or foods to reduce procedural pain cannot be recommended as a research priority in this population.
For funders: Further funding for well conducted sufficiently powered trials of sweet solutions for procedural pain management are warranted in young children from one to three years of age. As there is no uncertainty as to the calming effects of sweet solutions compared to placebo or no treatment in infants during single episodes of painful procedures (Bueno 2013; Stevens 2013; Harrison 2010c), further placebo controlled trials of sweet solutions should not be funded unless they meet existing knowledge gaps. Such existing gaps include minimal effective dose of sweet solutions, effect of repeated doses of solutions over weeks to months in preterm and/or sick hospitalised infants, and effects of concomitant treatments such as opioid analgesics. As there are alternative effective pain management strategies for school‐aged children, and sweet solutions seem to have no analgesic effects, funding for studies of analgesic effects of sweet solutions are not warranted in this population.