|LETTER TO THE EDITOR
|Year : 2011 | Volume
| Issue : 2 | Page : 136-138
Effect of oral sucrose on pain during DPT immunization in older infants
Dipankar Chattopadhyay1, Purnima Kundu2, Sova Gunri3, Sukamal Bisoi4
1 Associate Professor, Department of Community Medicine, Institute of Post-Graduate Medical Education and Research, Kolkata, India
2 Senior Lecturer, West Bengal Government College of Nursing, Kolkata, India
3 Senior Sister Tutor, School of Nursing, Balurghat, South Dinajpur, West Bengal, India
4 Associate Professor, Department of Community Medicine, R. G. Kar Medical College, Kolkata, India
|Date of Web Publication||22-Sep-2011|
Associate Professor, Department of Community Medicine, Institute of Post-Graduate Medical Education and Research, Kolkata
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chattopadhyay D, Kundu P, Gunri S, Bisoi S. Effect of oral sucrose on pain during DPT immunization in older infants. Indian J Public Health 2011;55:136-8
|How to cite this URL:|
Chattopadhyay D, Kundu P, Gunri S, Bisoi S. Effect of oral sucrose on pain during DPT immunization in older infants. Indian J Public Health [serial online] 2011 [cited 2020 Feb 26];55:136-8. Available from: http://www.ijph.in/text.asp?2011/55/2/136/85254
In the civilized world nobody should suffer from pain. This is truer for the little ones who sadly suffer from pain in the course of different immunization procedures. Pain during immunization by injections has been recognized as a factor leading to objection to childhood immunization by the parents. Injection of vaccines is the most common iatrogenic source of distress leading to increase in vaccine drop-outs.  Since there is no alternative to injection for some vaccines the strategies for pain reduction during the procedure should be explored.
Different aspects of immunization have been reviewed for pain reduction which includes site of injection, needle length and gauge, vaccine adjuvant, topical anesthetic agents, non-pharmacologic strategies and use of oral sucrose.  But the literature in this area is often anecdotal and based on experience rather than research.
The Neonatal/ Infant Pain Scale (NIPS) is a behavioral scale and can be utilized in infants. The tool uses the behaviors indicative of infant pain. It composed of six indicators: facial expression, cry, breathing patterns, arms and legs movement and state of arousal. Each behavioral indicator is scored with 0 or 1 except for "cry" which is scored with 0, 1, or 2. Infants are observed for one minute before, during and after the procedure in order to fully assess each indicator and a numeric score is assigned to each. Total pain score ranges from 0-7. A score greater than 3 in NIPS indicates pain. 
Sucrose use during immunization for infants less than 6 months of age has been studied by researchers in many countries. But sucrose use as a routine procedure during immunization is yet to be recommended. There may be a conflict of priority between exclusive breast feeding and pain alleviation by oral sucrose in that age group. All first year vaccine doses except measles are to be completed by 14 weeks of age. Postponement of vaccination is more hazardous than the pain. But, if there is proven and definite advantage of sucrose use during immunization on pain perception of infants its contradiction with exclusive breastfeeding may be sorted out.
Thus this experimental study of infants aged 6 months or more attending the MCH clinic of Howrah General Hospital, West Bengal, India for DPT vaccination in the months of December 2009 and January 2010 was undertaken. Ethical and administrative clearance was sought and obtained from the appropriate authority. Since the institutional ethical committee permitted to undertake the study amongst infants aged 6-11 months all such infants attending the clinic during the study period and whose guardians agreed to participate in the study by giving written informed consent were included in the study. The participants were coded with unique numbers to maintain anonymity. The selected children were assigned to study and control groups by randomization to receive solutions of 2 ml saturated sucrose solution or sterile water according to the bottle-code containing closed envelope technique. Solutions were drawn from coded bottles under standard aseptic condition and administered by syringe just placed in the mouth so that the solution comes into contact with the anterior aspect of the tongue. The nurse was blinded to the nature of the solutions. She administered all the test solutions given by mouth over a period of up to 30 seconds. Immediately thereafter (within thirty seconds) DPT was administered in the antero-lateral aspect (outer side) of mid thigh. All infants were awake at the time of the procedure and they were observed for three minutes by using Neonatal/ Infant Pain Scale (NIPS) which is recommended for children less than one year old. 
Analysis of data was done by standard statistical methods. Unpaired student's t-test of significance was employed.
Age and sex distribution are almost same in both study and control group. The number of acceptors of DPT in the last two months of infancy is only 5% of the infants studied.
25 (83.3%) infants in the study group had 1-3 pain score indicating no pain due to immunization and the remaining 5 (16.7%) in that group had pain score of 4 which is the lowest cut off limit of pain sensation in the pain scale (NIPS) used in this study. On the other hand 20 (66.7%) infants of the control group had 4- 6 NIPS score, though the pain score of 13 (43.3%) of them is 4; the remaining 10 (33.3%) had 2-3 pain score.
[Table 1] show that the difference between means of NIPS score of cases and controls is statistically very significant and not by chance (P< 0.001) [Table 1].
|Table 1: Pain scores (0-7 NIPS scale) of infants receiving sucrose or control solution|
Click here to view
Each infant is supposed to have 8 shots of BCG, DPT, Hepatitis B and Measles. All these are undoubtedly very painful for the baby and the problem should no longer be set aside since more and more vaccinations are being added to the schedule, effectively turning our children into human pin cushions. Does this failure to avoid or minimize pain of infants constitute child abuse? 
There are several available options to accomplish the objective of minimizing pain during vaccination of infants which need serious consideration of all concerned. Of them breast feeding during vaccination, anesthetic gel application to numb the site of injection or giving the baby a little sugar solution prior to injections have been shown to comfort him and reduce pain.  It is thought that the analgesic effect of oral sucrose is mediated via opioid receptors because in animal studies, this effect can be blocked by naloxone. 
Lindh et al.,  showed less crying and less change in modified behavioral pain scores, as well as lower parent and nurse visual analog scale scores, for 3-month-old children who received local application of anesthetic cream and oral glucose, compared with placebo cream plus sterile water, before DPT immunization.
The present short study of 6-11 month-old infants showed that the difference between means of NIPS score of the study group of sucrose solution and control group of sterile water is statistically very significant (P< 0.001) and oral sucrose solution is thus recommended as a feasible means of minimizing pain of vaccination by injection. However, the major limitation of the study was its inadequacy of sample size.
Although sucrose use has been studied by many researchers and most of them claimed its efficacy to reduce immunization pain in infancy, a systematic research should be initiated to determine its optimum concentration with and without other modalities such as nonnutritive sucking, parental contact, breast feeding during vaccination, anesthetic gel application to numb the site of injection etc. Apart from behavioral pain scores objective markers like salivary cortisol measurement may also be employed. At this time, however, there seem to be enough preliminary evidence to recommend sucrose use as a routine during immunization of infants by unavoidable injections. 
| References|| |
|1.||Karpasea-Jones J. Vaccination pain in children: A problem we should all take seriously. 2011. Available from: http://www.brighthub.com/parenting/infants-toddlers/articles/97972.aspx. [Last accessed on 2011 Feb 25]. |
|2.||Schechter NL, Zempsky WT, Cohen LL, McGrath PJ, McMurtry CM, Bright NS. Pain reduction during pediatric immunizations: Evidence-based review and recommendations. Pediatrics 2007;119:e1184-98. |
|3.||Pain Rating Scales for Patient Assessment. Available from: http://www.anes.ucla.edu/uclapainmanagement_ratingscales.php. [Last accessed on 2011 Feb 25]. |
|4.||Blass E, Fitzgerald E, Kehoe P. Interactions between sucrose, pain and isolation distress. Pharmacol Biochem Behav 1987;26:483-9. |
|5.||Lindh V, Wiklund U, Blomquist HK, Hakansson S. EMLA cream and oral glucose for immunization pain in 3-month-old infants. Pain 2003;104:381-8. |