Sucrose before Vaccination can Reduce pain

How to Stop the Hurt -- Sucrose Prior to Infant Vaccinations:
A Best Evidence Review Medscape CME/CE Posted 06/16/2008

Charles P. Vega, MD

Vaccination is the most common procedure performed in infancy, although parents might have significant concerns regarding the pain associated with routine vaccinations. Moreover, painful experiences very early in life can promote somatization later in life. Oral sucrose has been demonstrated to reduce pain reactions among neonates, and the current study examines this simple intervention prior to administration of routine vaccination at 2 and 4 months of age.

Participants received either a 24% disaccharide solution at a dose of 0.6 mL/kg, or matching placebo. Infants were not swaddled, cuddled, or restrained during vaccination or the ensuing data collection period.

Sucrose has previously been demonstrated to improve outcomes among neonates undergoing painful procedures. In an analysis of 21 randomized controlled trials involving 1616 infants, sucrose at a wide range of doses (0.012 mg to 0.12 mg) improved the rate of crying at 30 and 60 seconds after heel lance.^[8] However, sucrose was not effective in reducing heart rate at 1 and 3 minutes after heel lance.

Some practices employ other analgesic measures to reduce the pain of pediatric vaccinations. The application of the lidocaine-prilocaine patch prior to the first measles-mumps-rubella vaccine among children at least 12 months of age resulted in a significant reduction in Behavior Pain Scale scores vs placebo treatment.^[9] Moreover, rates of irritability after vaccination were 16% in the lidocaine-prilocaine group vs 31% in the placebo group, and the antibody responses in the 2 groups to the vaccine components were similar.

Parents may also pretreat their children with oral analgesic medications prior to appointments for vaccination, and a study of acetaminophen delivered prior to administration of the diphtheria-pertussis-tetanus toxoids-polio vaccine largely supports this practice.^[10] Compared with placebo, acetaminophen reduced the risk for fever greater than 38 degrees Celsius from 44% to 27%. Rates of behavioral changes after vaccination were 0.9% among the acetaminophen group vs 13% with placebo. However, acetaminophen was superior to placebo for primary vaccinations at 2 to 6 months of age but not for booster vaccination at 18 months of age. At the 18-month vaccination, the overall rate of systemic and local reactions was higher in both the acetaminophen and placebo groups. Another study has demonstrated that neither acetaminophen nor ibuprofen was effective in reducing the risk for local reactions such as erythema and swelling following the fifth diphtheria-tetanus toxoids-acellular pertussis vaccination.

Two key questions remain regarding the implementation of sucrose for the prevention of pain in pediatric vaccinations. First, the weight-based dosing algorithm for sucrose in the current study certainly appeared effective, but the dosage range used in different studies has generally been quite wide. Further research should address the issue of the optimal dose of sucrose. In addition, it would be very easy to conceive that using other analgesics such as acetaminophen in addition to sucrose could be synergistic in improving pain and behavior after vaccination. Moreover, the use of antipyretic medications could also reduce the risk for postvaccination fever.

Regarding the practical utility of different methods of analgesia for routine infant vaccinations, lidocaine-prilocaine can be difficult to apply and maintain in place for the 30 minutes required for effective analgesia prior to procedures.

Oral analgesics must also be delivered well before the vaccine is administered to be effective, and they expose infants and children to the remote possibility of significant adverse events.

In contrast, sucrose appears to be a readily available and applicable means to reduce infants' pain with vaccination. It is inexpensive and safe. Sucrose can also help parents to feel actively involved in protecting their infant from pain, and this should help increase acceptance of routine vaccinations. And that outcome should taste just like sugar for clinicians.