Originally published by 2 Minute Medicine® (view original article). Reused on AccessMedicine with permission.

1. Breastfeeding was recommended as a first-line neonatal analgesic for procedures done in non-tertiary care in Kenya.

2. When breastfeeding is unavailable, expressed breastmilk was recommended as a first-line analgesic, with oral sugar as a second-line analgesic.

Evidence Rating Level: 1 (Excellent)

Study Rundown:

In low and middle income countries (LMICs), painful neonatal procedures are often performed without adequate use of analgesia. In addition to ethical concerns, unaddressed pain in preterm NICU patients is also correlated with delayed growth and poorer neurodevelopment outcomes. However, past research on neonatal analgesia are discrete, failing to compare many forms of analgesia in a single study. As well, currently existing guidelines in some countries cannot be applied to other countries, due to disparities in resource availability and varying cultural considerations.

In the current study, the National Pain Guideline Group (NPGG) conducted a systematic review and meta-analysis that sought to develop evidence-based recommendations for neonatal analgesia guidelines, specific to non-tertiary settings in Kenya. The NPGG recommended that breastfeeding, with skin-to-skin contact, should be a first-line analgesic. When this is not possible, expressed breastmilk should be the first choice, and an oral sugar solution the second choice, administered prior to the procedure. Skin-to-skin contact or non-nutritive sucking should take place during the procedure.

The study’s inclusion of only randomized or quasi-randomized controlled trials was a large strength of its design. Naturally, the study design limits its recommendations to be specific to Kenya only, and may have poorer generalizability to countries with greater resources. Nonetheless, these were the first neonatal analgesic guidelines generated for routine procedures, marking a large step forward for neonatal care in Kenya.

In-depth [systematic review and meta-analysis]:

This study involved a literature search from 1953 to 2019. Neonatal procedures common to non-tertiary settings in Kenya were included, such as heel pricks, intramuscular injections, and arterial punctures. Pharmacological analgesics were included in the search, but ultimately excluded by the NPGG due to low resource availability. Six pain outcomes were included, such as heart rate, oxygen saturation, premature infant pain profile (PIPP) score, and neonatal infant pain scale (NIPS) score.

The NPGG concluded with moderate certainty that breastfeeding was superior to expressed breastmilk: In the narrative synthesis, 2 out of 3 studies (n=136) showed a large effect size demonstrating superiority. As well, they concluded with low certainty that breastfeeding was superior to oral sugar: In the meta-analysis, no difference in PIPP score was found with a standard mean difference (SMD) of -0.21 (95% CI of -0.78 to 0.35, n=346). However, a reduction in NIPS was found (SMD –1.51, 95% CI –2.48 to –0.53, n=182). There was moderate certainty that oral sugar was superior to expressed breastmilk: 9 out of 14 studies (64%) in the narrative synthesis demonstrated superiority, while 5 studies demonstrated equivalence. No difference was found in the meta-analysis (PIPP: SMD 0.55, 95% CI –0.03 to 1.12, n=309).

Overall, breastfeeding was recommended as the first-line analgesic: The NPGG also took into consideration that breastfeeding had no side effects and no cost to the state. When breastfeeding is unavailable, the NPGG recommended expressed breastmilk over oral sugar, despite their deeming of oral sugar as moderately superior. This was largely done to prevent the promotion of infants sugar water at home, due to concerns regarding contaminated water and neonates being fed copious amounts of sugar if undergoing multiple procedures.

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