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Karmienie piersią lub mlekiem matki w łagodzeniu bólu podczas wykonywania procedur medycznych u noworodków

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Background

Physiological changes brought about by pain may contribute to the development of morbidity in neonates. Clinical studies have shown reduction in changes in physiological parameters and pain score measurements following pre‐emptive analgesic administration in situations where the neonate is experiencing pain or stress. Non‐pharmacological measures (such as holding, swaddling and breastfeeding) and pharmacological measures (such as acetaminophen, sucrose and opioids) have been used for this purpose.

Objectives

The primary objective was to evaluate the effectiveness of breastfeeding or supplemental breast milk in reducing procedural pain in neonates. The secondary objective was to conduct subgroup analyses based on the type of control intervention, gestational age and the amount of supplemental breast milk given.

Search methods

We performed a literature search using the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 10), MEDLINE (1966 to February 2011), EMBASE (1980 to February 2011), CINAHL (1982 to February 2011), abstracts from the annual meetings of the Society for Pediatric Research (1994 to 2011), and major paediatric pain conference proceedings. We did not apply any language restrictions.

Selection criteria

Randomised controlled trials (RCTs) or quasi‐RCTs of breastfeeding or supplemental breast milk versus no treatment/other measures in neonates were eligible for inclusion in this review. The study must have reported on either physiologic markers of pain or validated pain scores.

Data collection and analysis

We assessed the methodological quality of the trials using the information provided in the studies and by personal communication with the authors. We extracted data on relevant outcomes, estimated the effect size and reported this as a risk ratio (RR), risk difference (RD) and weighted mean difference (MD) as appropriate.

Main results

Of twenty eligible studies, ten evaluated breastfeeding and ten evaluated supplemental breast milk. Sixteen studies analysed used heel lance and four used venepuncture as procedure. We noted marked heterogeneity in control intervention and pain assessment measures among the studies. Neonates in the breastfeeding group had statistically a significantly lower increase in heart rate, reduced proportion of crying time and reduced duration of first cry and total crying time compared to positioning (swaddled and placed in a crib), holding by mother, placebo, pacifier use, no intervention or oral sucrose group, or both.

Premature Infant Pain Profile (PIPP) scores were significantly lower in the breastfeeding group compared to positioning, placebo or oral sucrose group, or both. However, there was no statistically significant difference in PIPP scores when compared to no intervention. Douleur Aigue Nouveau‐ne scores (DAN) were significantly lower in the breastfeeding group compared to the placebo group and the group held in mother's arms, but not when compared to the glucose group. Neonatal Infant Pain Scale (NIPS) was significantly lower in the breastfeeding group compared to the no intervention group, but there was no difference when compared to the oral sucrose group. The Neonatal Facial Coding System (NFCS) was significantly lower in the breastfeeding group when compared to oral glucose, pacifier use, holding by mother and no intervention, but no difference was found when compared to formula feeding.

Supplemental breast milk yielded variable results. Neonates in the supplemental breast milk group had a significantly lower increase in heart rate, a reduction in duration of crying and a lower NFCS compared to the placebo group. Neonates in the supplemental breast milk group had a significantly higher increase in heart rate changes when compared to the sucrose group. Sucrose (in any concentration, i.e. 12.5%, 20%, 25%) was found to reduce the duration of cry when compared to breast milk, as did glycine, pacifier use, rocking, or no intervention. Breast milk was found not to be effective in reducing validated and non‐validated pain scores such as NIPS, NFCS, and DAN; only being significantly better when compared to placebo (water) or massage. We did not identify any study that has evaluated safety/effectiveness of repeated administration of breastfeeding or supplemental breast milk for pain relief.

Authors' conclusions

If available, breastfeeding or breast milk should be used to alleviate procedural pain in neonates undergoing a single painful procedure rather than placebo, positioning or no intervention. Administration of glucose/sucrose had similar effectiveness as breastfeeding for reducing pain. The effectiveness of breast milk for painful procedure should be studied in the preterm population, as there are currently a limited number of studies in the literature that have assessed it's effectiveness in this population.

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Karmienie piersią lub mlekiem matki w łagodzeniu bólu podczas wykonywania procedur medycznych u noworodków

Karmienie piersią zmniejsza nasilenie bólu u noworodków poddawanych bolesnym procedurom medycznym. Leki przeciwbólowe są zazwyczaj stosowane w przypadku większych zabiegów, ale nie zawsze są podawane podczas niewielkich bolesnych procedur, takich jak pobieranie krwi (z pięty lub żyły). Istnieje wiele metod niefarmakologicznych, które mogą być stosowane u dzieci w celu zmniejszenia bólu. Są to kołysanie, otulanie, ssanie smoczka lub podawanie słodkiego płynu (np. sacharoza lub glukoza). Różne badania przeprowadzone w grupie niemowląt wykazały, że karmienie piersią jest dobrą metodą zmniejszenia odczuwania przez nie bólu podczas drobnych bolesnych procedur medycznych. Badania te były przeprowadzone u dzieci urodzonych w prawidłowym terminie porodu i wykazały, że karmienie piersią jest skuteczne na podstawie skrócenia czasu płakania i niższej punktacji odczuwania bólu w różnych skalach zaprojektowanych dla niemowląt. Podawanie mleka matki za pomocą strzykawki nie wykazało takiego samego efektu jak karmienie piersią. Nie przeprowadzano badań wśród dzieci przedwcześnie urodzonych, dlatego też nowe badania są potrzebne w celu ustalenia czy podawanie mleka matki tym niemowlętom jest skuteczne w uśmierzaniu bólu.