Füsun OKAN, EMİNE ASUMAN ÇOBAN, Zeynep İNCE, Gülay CAN

Preterm yenidoğanlarda analjezi: Sükroz ve glükozun karşılaştırmalı etkileri

Sağlıklı preterm yenidoğanlarda farklı karbonhidrat solüsyonlarının ağrılı uyaran sonrası ortaya çıkan fizyolojik ve davranışsal değişiklikler üzerine etkisinin araştırılması. Yöntem: Çalışma prospektif, randomize, çift-kör olarak planlandı. Çalışma grubundaki topuktan kan alınacak otuz bir sağlıklı preterm bebeğin ağzına topuk delinmesinden 2 dk. önce üç solüsyondan biri verildi: A solüsyonu (2 mL, % 20 sükroz), B solüsyonu (2 mL, % 20 glükoz), C solüsyonu (kontrol solüsyonu, 2 mL distile su). Her bebek ayrı ayrı üç farklı solüsyonla randomize edilerek çalışıldı. Ağrılı uyarana davranış yanıtları ağlama süresi (ilk çığlıkla başlayan ağlama süresi ve toplam ağlama süresi) ölçülerek ve yenidoğan yüz kodlama sistemiyle (YYKS) mimikler puanlanarak; fizyolojik yanıtları ise kalp atım hızı (KAH), dakikadaki solunum sayısı (DSS) ve oksijen satürasyonu değişiklikleri ile ölçüldü. Bulgular: Bebeklerin ortalama (±SS) doğum ağırlığı, 1,401 (406) g gebelik yaşı 30.5 (2.7) hafta; test sırasındaki postmenstrüel yaş 32.3 (1.5) hafta, postnatal yaş yirmi (16) gündü. Sükroz, glükoz ve kontrol gruplarının kan alma süreleri farklı değildi (p=0.669). İlk çığlıkla başlayan ağlama süresi ve toplam ağlama süresi sükroz grubunda en kısa bulunmakla birlikte, glükoz grubu ile anlamlı fark yoktu. Distile su grubunda ise, ağlama süreleri sükroz ve glükoz alan bebeklere göre anlamlı olarak uzundu (p=0.005 ve p=0.007). Ağrılı uyarı sonrası YYKS puanı distile su alan bebeklerde 4. ve 5. dk.’da sükroz ve glükoz alanlara göre anlamlı olarak yüksek bulunurken (p=0.009 ve p=0.046), glükoz ve sükroz alanlar arasında fark yoktu. Ağrılı uyaran sonrası bebeklerin KAH'da ilk 3 dk.’da öncesindeki bazal değere göre anlamlı bir artma oldu, uyarıdan sonraki 1. dk.’da KAH en yüksek değerdeydi. Distile su alan bebeklerde en yüksek KAH, sükroz ve glükoz alanlara göre anlamlı olarak fazlaydı (p=0.007), sükroz ve glükoz alanlar arasında fark bulunmadı. Ağrılı uyarıdan sonra bebeklerin DSS ve SaO2 değişiklikleri açısından üç grup arasında fark yoktu. Sonuç: Çalışmamızda topuk delinmesinden önce oral yolla verilen % 20'lik sükroz ve glükozun preterm ağrı yanıtını azalttığı ve her iki karbonhidratın etkilerinin benzer olduğu gösterildi.

Analgesia in preterm newborns: The comparative effects of sucrose and glucose

To evaluate the effectiveness of different oral carbohydrate solutions for the prevention of pain-induced physiological and behavioral changes in healthy preterm babies. Methods: The study was designed to be double-blind and placebo-controlled. Thirty-one healthy babies (postmenstruel age at procedure less than 37 weeks) who were having blood drawn by heel stick were studied. Each baby was studied three times and was randomly allocated to receive solution A (2 ml of 20 % sucrose), solution B (2 ml of 20 % glucose) or solution C (2 ml of sterile water) into the mouth by a syringe, two minutes before lancing. Behavioral responses to the painful stimulus were measured by duration of crying and facial expressions (Neonatal Facial Coding System, NFCS) and physiological responses were measured by heart rate (HR), respiratory rate (RR) and oxygen saturation changes (SaO2). Results: Babies had a mean birth weight (±SD) of 1401 (406) g and gestational age of 30.5 (2.7) weeks; at the time of the procedure the postmenstruel age was 32.3 (1.5) weeks and the postnatal age was 20 (16) days. There was no significant difference in the time spent squeezing the heel between the three groups (p=0.669). However, after the heel prick of both the sucrose and glucose groups the first cry and the total crying time was significantly reduced (p=0.005 and p=0.007). When the babies received placebo they showed a significantly higher NFCS score at 4 and 5 minutes after the heel prick (p=0.009 and 0.046 respectively). Following painful stimulus HR increased significantly in the 3 minutes compared with the resting rate, and at the first minute the mean of the HR was found to be significantly higher than the placebo group (p=0.007). However; during the study there were no significant differences in the RR and SaO2 between the three groups at any time. Conclusion: In this study, we concluded that both sucrose and glucose administered orally before a heel lance reduce the pain response in preterm infants.

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1. Patent J. The Sensory Pathways. In: Patent J, ed. Neurological Differantial Diagnosis. London: Sringer-Verlag, 1996, 225-45.
2. Barker D, Rutter N. Exposure to invasive procedures in neonatal intesive care unit admissions. Arch Dis Child 1995; 72:F 47-8.
3. Goldstein R, Brazzy J. Narcotic sedation stabilizes arterial blood pressure fluctations in sick premature infants. J Perinatol 1991;11:365-71.
4. Me Intosh N, Van Veen L, Bramayer H. Alleviation of the pain of heel prick in preterm infants. Arch Dis Child 1994; 70:F177-81.
5. Kaminski J, Hall W. The effect of shooting music on neonatal behavioral states in the hospital newborn nursery. Neonatal Netw 1996; 5:45-54.
6. Field T, Goldson E. Pacifying effects of nonnutritive sucking on term and preterm neonates during heelstick procedures. Pediatrics 1984; 74:1012-5.
7. Blass EM, Shah A. Pain-reducing properties of sucrose in human newborns. Chem Sens 1995; 20:29-35.
8. Fearson I, Kiskevsky BS, Hains SM, Muir DW, Tranmer J. Swaddling after heel lance: age-specific effects on behavioral recovery in preterm infants. J Dev Behav Pediatr 1997; 8:222-32.
9. Blass EM, Snide DJ, Weller A. Stres-reducing effects of ingesting milk, sugars, and fats. A developmental perspective. Ann N Y Acad Sci 1989; 575:292-305.
10. Ballard JL, Khourjy JC, Wedig K, Wang L, Eilers-Walsman BL, Lipp R. New Ballard score expanded to include extremely premature infants. J Pediatr 1991; 119: 417-23.
11. Grunau RVE, Craig KD. Pain expression in neonates: facial action and cry. Pain 1987; 28:395-410.
12. Owens ME, Todth EH. Pain in infancy: neonatal reaction to heel lance. Pain 1984; 20:77-86.
13. Larsson BA, Norman M, Bjerring P, Egekvist H, Lagercratz H, Olsson GL. Regional variations in skin perfusion and skin thickness may contribute to varying efficacy of topical, local anaesthetics in neonates. Pediatr Anaesth 1996; 6:107-10.
14. Larsson BA, Nulman I, Goldbach M, IPP M, Koren G. Does a local anaesthetic cream (EMLA) alleviate pain from heel-lancing in neonates? Acta Anaestheziol Scand 1995; 23:1028-31.
15. Blass EM, Hoffmayer LB, Sucrose as analgesic in newborn infants. Pediatrics 1991; 87:215-18.
16. Ren K, Blass EM, Zhou Q, Dubner R. Suckling and sucrose ingestion persistent hyperalgezia and spinal Fos expression after forepaw inflammation in rats. Proc Natl Acad Sci 1997; 94:1471-5.
17. Bucher HU, Moser T, Siebenthal K, Keli M, Wolf M, Due G. Sucrose reduces pain reaction to heel lancing in pretem infants. Pediatr Res 1995; 38:332-35.
18. Ramenghi LA, Evans DJ, Levene MI. "Sucrose analgesia": absorptive mechanism or taste perception? Arch Dis Child Fetal Neonatal Ed 1999, 80: F146-7.
19. Cheng LH, Robinson PP. The distribution of fungiform papillae and taste buds on the human tongue. Arch Oral Biol 1991; 36:583-9;
20. Skogsdal, Eriksson M, Scholin J. Analgesia in newborns given oral glucose. Acta Pediatr 1997; 86:217-8.
21. Johnston CC, Strada ME. Acute pain resonse in infants: a multidimentional description. Pain 1986; 24:373-82.
22. Craig KD, Whitfield MF, Grunau RVE, Linton J, Hadjistavropoulos HD. Pain in the preterm neonate: behavioural and physiological indices. Pain 1993; 52:287-99.
23. Grunau RVE, Whitfield MF, Petrie JH. Pain sensitivity and temperament in extremely low-birth-weight premature toddlers and preterm and full-term controls. Pain 1994; 58:341-46.
24. Stevens BJ, Johnston CC, Horton L. Factors that influence the behavioral pain responses of premature infants. Pain 1994; 59:101-9.
25. Carbajal R, Lenclen R, Gajdos V, Jugie M, Paupe A. Crossover trial of analgesic efficacy of glucose and pacifier in very pretrm neonates during subcutaneous injections. Pediatrics 2002; 110:389-93.
26. Grunau RV, Johnston CC, Craig KD. Neonatal facial and cry responses to invasive and non-invasive procedures. Pain 1990; 42:295-305.
27. Stevens B, Taddio A, Ohlsson A, Einarson T. The efficacy of sucrose for receiving procedural pain in neonates-a systemic review and meta-analysis. Acta Pediatr 1997; 86:837-41.
28. Ramenghi L. Reduction of pain responses in premature infants using intraoral sucrose. Arch Dis Child 1996; 74:F126-28.