International Journal of Clinical Pharmacy

, Volume 37, Issue 3, pp 529–536 | Cite as

Reducing pain from heel lances in neonates following education on oral sucrose

  • Mark ShenEmail author
  • Gladys El-Chaar
Research Article


Background Heel lances are common painful procedures performed in the neonatal intensive care unit (NICU). Upon observation, pain relieving methods were not consistently applied during such procedures in our institution. Objective The objective of this three-phase quality improvement project was to improve pain management for heel lance-induced pain in the NICU. Setting This study took place in a 27-bed NICU in a level IV perinatal regional center at a 591 bed university affiliated teaching hospital in New York, United States. Method Study Phase 1, involving 25 neonates, documented baseline pain management strategies and pain scores, which were measured before, during, and after heel lancing using the Neonatal Pain Agitation and Sedation Scale (N-PASS). In Study Phase 2, nurses and physicians were educated on the use of sucrose and non-pharmacological measures to prevent and manage heel lance-induced pain. Study Phase 3 (Post education evaluation), had the same procedure as Study Phase 1, and involved another host of 25 neonates. Main outcome measure Pain scores were compared in groups of neonates in Phase 1 (before education) and Phase 3 (after education) before, during and after heel lancing. Other outcome measures included quantifying the use of sucrose and documenting any adverse effects. Results We found an 84 % increase in the use of sucrose post-education (Phase 3), and most importantly, an 11.2 % reduction in pain scores from heel lances in neonates. Four neonates who did not receive sucrose in Phase 3 had higher pain scores during heel lancing than those who did (3.5 and 2.38, respectively). There were no adverse effects reported with sucrose. Conclusion Health care providers were aware of sucrose but were not using this treatment modality, despite its availability on nursing units. Education was effective in the adoption of sucrose use, leading to a reduction in pain from heel lances in neonates.


Education Heel lance Neonate Newborn Pain Pharmacist Sucrose 



The authors wish to thank Margaret Murphy, MS, RNC, NNP and the NICU nurses for their assistance and supervision with the initial N-PASS scoring and other aspects of the study. Additionally, the authors would like to thank Melissa Fazzarri, PhD for her assistance with the statistical analysis and Kelly Winters for editorial assistance.


This quality improvement project received no funding from external sources.

Conflicts of interest

Neither author has conflicts of interest, relevant financial or personal relationships to disclose.


  1. 1.
    Carbajal R, Rousset A, Danan C, Coguery S, Nolent P, Ducrocg S, et al. Epidemiology and treatment of painful procedures in neonates in intensive care units. JAMA. 2008;300(1):60–70.CrossRefPubMedGoogle Scholar
  2. 2.
    Anand KJ, Hickey PR. Pain and its effects in the human neonate and fetus. N Engl J Med. 1987;317(21):1321–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Duhn LJ, Medves JM. A systematic integrative review of infant pain assessment tools. Adv Neonatal Care. 2004;4(3):126–40.CrossRefPubMedGoogle Scholar
  4. 4.
    Ramsay DS, Lewis M. The effects of birth condition on infants’ cortisol response to stress. Pediatrics. 1995;95(4):546–9.PubMedGoogle Scholar
  5. 5.
    Taddio A, Goldbach M, Ipp M, Stevens B, Koren G. Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet. 1995;345(8945):291–2.CrossRefPubMedGoogle Scholar
  6. 6.
    Whitfield MF, Grunau RE. Behavior, pain perception, and the extremely low-birth weight survivor. Clin Perinatol. 2000;27(2):363–79.CrossRefPubMedGoogle Scholar
  7. 7.
    Brummelte S, Grunau RE, Chau V, Poskitt KJ, Brant R, Vinall J, et al. Procedural pain and brain development in premature newborns. Ann Neurol. 2012;71(3):385–96.CrossRefPubMedCentralPubMedGoogle Scholar
  8. 8.
    Hall RW, Anand KJS. Physiology of pain and stress in the newborn. Neoreviews. 2005;6(2):e61–8.CrossRefGoogle Scholar
  9. 9.
    Harrison D, Beggs S, Stevens B. Sucrose for procedural pain management in infants. Pediatrics. 2012;130(5):918–25.CrossRefPubMedGoogle Scholar
  10. 10.
    Cignacco E, Hamers JP, Stoffel L, van Lingen RA, Gessler P, McDougall J, et al. The efficacy of non-pharmacological interventions in the management of procedural pain in preterm and term neonates. A systematic literature review. Eur J Pain. 2007;11(2):139–52.CrossRefPubMedGoogle Scholar
  11. 11.
    American Academy of Pediatrics; Committee on Fetus and Newborn; Canadian Paediatric Society; Fetus and Newborn Committee. Prevention and management of pain in the neonate. An update. Adv Neonatal Care. 2007;7(3):151–60.CrossRefGoogle Scholar
  12. 12.
    Lehr VT, Taddio A. Topical anesthesia in neonates: clinical practices and practical considerations. Semin Perinatol. 2007;31(5):323–9.CrossRefPubMedGoogle Scholar
  13. 13.
    Carbajal R, Lenclen R, Jugie M, Paupe A, Barton BA, Anand KJ. Morphine does not provide adequate analgesia for acute procedural pain among preterm neonates. Pediatrics. 2005;115(6):1494–500.CrossRefPubMedGoogle Scholar
  14. 14.
    Holsti L, Grunau RE. Considerations for using sucrose to reduce procedural pain in preterm infants. Pediatrics. 2010;125(5):1042–7.CrossRefPubMedCentralPubMedGoogle Scholar
  15. 15.
    Chen AL, Chen TJ, Waite RL, Reinking J, Tung HL, Rhoades P, et al. Hypothesizing that brain reward circuitry genes are genetic antecedents for pain sensitivity and critical diagnostic and pharmacogenomic treatment targets for chronic pain conditions. Med Hypotheses. 2009;72(1):14–22.CrossRefPubMedCentralPubMedGoogle Scholar
  16. 16.
    Wood PB. Role of central dopamine in pain and analgesia. Expert Rev Neurother. 2008;8(5):781–97.CrossRefPubMedGoogle Scholar
  17. 17.
    Jiao R, Yang C, Zhang Y, Xu M, Yang X. Cholinergic mechanism involved in the nociceptive modulation of dentate gyrus. Biochem Biophys Res Commun. 2009;379(4):975–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Stevens B, Yamada J, Lee GY, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev. 2013;1:CD001069.PubMedGoogle Scholar
  19. 19. [Internet]. Assessment Guidelines [updated 2009 Oct 24; cited 2013 Feb 20].
  20. 20.
    Facchinetti F, Bagnoli F, Bracci R, Genazzani AR. Plasma opioids in the first hours of life. Pediatr Res. 1982;16(2):95–8.CrossRefPubMedGoogle Scholar
  21. 21.
    Powell CV, Kelly AM, Williams A. Determining the minimum clinically significant difference in visual analog pain score for children. Ann Emerg Med. 2001;37(1):28–31.CrossRefPubMedGoogle Scholar
  22. 22.
    Taddio A, Shah V, Hancock R, Smith RW, Stephens D, Atenafu E, et al. Effectiveness of sucrose analgesia in newborns undergoing painful medical procedures. CMAJ. 2008;179(1):37–43.CrossRefPubMedCentralPubMedGoogle Scholar
  23. 23.
    Shah V, Ipp M, Sam J, Einarson TR, Taddio A. Eliciting the minimally clinically important difference in the pain response from parents of newborn infants and nurses. In: Canadian Pediatric Society 81st Meeting. Montreal, QC: Pulsus Group.Google Scholar
  24. 24.
    Slater R, Cornelissen L, Fabrizi L, Patten D, Yoxen J, Worley A, et al. Oral sucrose as an analgesic drug for procedural pain in newborn infants: a randomised controlled trial. Lancet. 2010;376(9748):1225–32.CrossRefPubMedCentralPubMedGoogle Scholar
  25. 25.
    Foster J, Spence K, Henderson-Smart D, Harrison D, Gray PH, Bidewell J. Procedural pain in neonates in Australian hospitals: a survey update of practices. J Paediatr Child Health. 2013;49(1):E35–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Wilkinson DJ, Savulescu J, Slater R. Sugaring the pill: ethics and uncertainties in the use of sucrose for newborn infants. Arch Pediatr Adolesc Med. 2012;166(7):629–33.CrossRefPubMedCentralPubMedGoogle Scholar
  27. 27.
    Lasky RE, van Drongelen W. Is sucrose an effective analgesic for newborn babies? Lancet. 2010;376(9748):1201–3.CrossRefPubMedGoogle Scholar
  28. 28.
    Anand KJ, Oberlander TF, Taddio A, Lehr VT, Walco GA. Analgesia and local anesthesia during invasive procedures in the neonate. Clin Ther. 2005;27(6):844–76.CrossRefPubMedGoogle Scholar
  29. 29.
    Carbajal R, Lenclen R, Gajdos V, Jugie M, Paupe A. Crossover trial of analgesic efficacy of glucose and pacifier in very preterm neonates during subcutaneous injections. Pediatrics. 2002;110(2 Pt 1):389–93.CrossRefPubMedGoogle Scholar
  30. 30.
    Grabska J, Walden P, Lerer T, Kelly C, Hussain N, Donovan T, et al. Can oral sucrose reduce the pain and distress associated with screening for retinopathy of prematurity? J Perinatol. 2005;25(1):33–5.CrossRefPubMedGoogle Scholar
  31. 31.
    Gibbins S, Stevens B, Hodnett E, Pinelli J, Ohlsson A, Darlington G. Efficacy and safety of sucrose for procedural pain relief in preterm and term neonates. Nurs Res. 2002;51(6):375–82.CrossRefPubMedGoogle Scholar
  32. 32.
    McCullough S, Halton T, Mowbray D, Macfarlane PI. Lingual sucrose reduces the pain response to nasogastric tube insertion: a randomised clinical trial. Arch Dis Child Fetal Neonatal Ed. 2008;93(2):F100–3.CrossRefPubMedGoogle Scholar
  33. 33.
    Johnston CC, Filion F, Snider L, Majnemer A, Limperopoulos C, Walker CD, et al. Routine sucrose analgesia during the first week of life in neonates younger than 31 weeks’ postconceptional age. Pediatrics. 2002;110(3):523–8.CrossRefPubMedGoogle Scholar
  34. 34.
    Johnston CC, Filion F, Snider L, Limperopoulos C, Majnemer A, Pelausa E, et al. How much sucrose is too much sucrose? Pediatrics. 2007;119(1):226.CrossRefPubMedGoogle Scholar

Copyright information

© Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2015

Authors and Affiliations

  1. 1.Department of PharmacyWinthrop-University HospitalMineolaUSA
  2. 2.Department of Clinical Pharmacy PracticeSt. John’s University College of Pharmacy and Health SciencesQueensUSA

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