**2. Sweet solutions in the clinical settings and guidelines**

The implementation of sweet solution for minor painful and invasive procedures in the NICU has been documented in many studies and extensive review of studies showed that sweet solutions have analgesic effects in young children up to one-year-old [16].

Study findings show that giving sweet solutions to young infants during painful procedures reduces painful responses and crying time tends to be shorter [9]. Different concentrations and dose were examined and showed to have a pain relieving effect. The most widely used sweet solution is sucrose [17]. Glucose is the second most commonly used solution, as it is available as prepared solution at clinics and hospitals [9]. All sweet solutions are administered in the same way, on the infants' lateral side of the tongue prior to or 2 min before the procedure through a syringe slowly over 30 s [9, 18]. Another administration technique is through the use of non-nutritive sucking using pacifier to improve its effectiveness [11, 19].

Sweet solution is a fast acting pain-relief intervention (within 10 seconds) [20]. Although there is no evidence yet about the dose-response effects [21], dose ranging from 0.5 to 2 mL of 12–24% strength show pain-relief effect [11, 22]. For premature neonates, dose is calculated in accordance to their weight/volume ratio. **Table 1** displays the doses according to week's gestation and kilograms. In preterm neonates, it is recommended to use multiple dose regimens instead of given one dose to reduce any risk of adverse effects such as chocking. Several clini-


**Table 1.** Doses according to week's gestation and kilograms and the sweetener used.

cal guidelines included the use of sweet solution for analgesia particularly for minor painful procedures. Heel lance followed by venipuncture were the top benefiting procedures of this analgesic measure [25–27]. Sweet solution may be used in infants aged 27 or more-week gestation. The volume administered for each age group should be as follow: 27–31 weeks' gestation (0.1–0.5 mL); 32–36 weeks' gestation (0.5–1 mL) and greater than 37 weeks' gestation (1–2 mL)


Source: Refs. [28, 29].

appropriate pain relief intervention. The most often cited causes for this paradox are the several myths surrounding the painful experience in the neonatal population, particularly the perception that the newborn is too immature to feel pain [5]. It is known that the knowledge about the presence of pain in newborns has greatly increased among health providers who are responsible for neonatal care [6], but it is not known how each professional puts such knowledge into practice [7]. Young children including neonates do not have the ability to verbalize their pain thus health care providers must recognize their pain. Not only unmanaged pain causes distress and delayed recovery but pain in infancy also has short-term (physiological and behavioral) and long-term developmental consequences (increased or decreased behavioral responses to pain). Although infant's pain is not expressed as conscious memory, memories of pain may be recorded biologically and alter brain development and subsequent behavior. Some recent studies have reported that simple and benign interventions such as oral sweet solutions [5, 8, 9], milk [10] or sucking a pacifier [11] reduce pain in neonates during procedures. Pain relieving effects of sweet solutions such as sucrose have been examined in term and preterm neonates [12, 13]. Glucose and other sweet tasting solutions have also been found to have pain relieving effects [9]. The effect of sugar on calming a crying baby during painful procedure is not new but there are historical references pertaining to the analgesic and calming benefits of sweet substances dating back to AD 632, when Prophet Mohammed recommended giving infants a well-chewed date [14]. Also Thorek, in his textbook, *Modern Surgical Technique*, published in 1938, explained his ideas of acceptable pediatric anesthesia: "Often no anesthesia is required. A sucker consisting of a sponge dipped in some sugar water

will often suffice to calm a baby" [15].

302 Pain Relief - From Analgesics to Alternative Therapies

**2. Sweet solutions in the clinical settings and guidelines**

solutions have analgesic effects in young children up to one-year-old [16].

The implementation of sweet solution for minor painful and invasive procedures in the NICU has been documented in many studies and extensive review of studies showed that sweet

Study findings show that giving sweet solutions to young infants during painful procedures reduces painful responses and crying time tends to be shorter [9]. Different concentrations and dose were examined and showed to have a pain relieving effect. The most widely used sweet solution is sucrose [17]. Glucose is the second most commonly used solution, as it is available as prepared solution at clinics and hospitals [9]. All sweet solutions are administered in the same way, on the infants' lateral side of the tongue prior to or 2 min before the procedure through a syringe slowly over 30 s [9, 18]. Another administration technique is through the use of non-nutritive sucking using pacifier to improve its effectiveness [11, 19].

Sweet solution is a fast acting pain-relief intervention (within 10 seconds) [20]. Although there is no evidence yet about the dose-response effects [21], dose ranging from 0.5 to 2 mL of 12–24% strength show pain-relief effect [11, 22]. For premature neonates, dose is calculated in accordance to their weight/volume ratio. **Table 1** displays the doses according to week's gestation and kilograms. In preterm neonates, it is recommended to use multiple dose regimens instead of given one dose to reduce any risk of adverse effects such as chocking. Several clini**Table 2.** Contraindications for the use of sweet solution as analgesic.

[5, 8, 9]. Dosage is usually expressed in mg. It is recommended to record the given dose and time on the neonates' medication sheet. Sweet solution does not need a doctor's order but it could be given by a nurse as needed, which is prepared in the pharmacy if not readily available in sterile container at floors. Once the container is open, the solution may be kept at the bedside for 24 hours if not Contaminated. It is important to record the opening date and time on the container. Sweet solution should not be used on infants less than 27-week gestations, infants who have suspected or proven gastrointestinal dysfunction/abnormalities such as ileus, obstruction, necrotizing enterocolitis or who are postoperative. Sweet solution should not be used for unstable or compromised neonates. **Table 2** lists the contraindications for the use of sweet solutions for analgesia.

Around the world more and more hospitals and clinics are implementing the use of sweet substances to reduce pain and discomfort among premature and mature infants. Yet important knowledge and research gaps concerning long-term analgesic effects of repeated administration of sweet solutions still exist. One reason could be related to the fact that the mechanism of sweet-taste-induced analgesia is still not precisely understood, which prevented the uptake of such intervention using research evidence from being used in practice.
