SUCROSE
“A spoon full of sugar helps the medicine go down!” Julie Andrews in “Mary Poppins”, (Walt Disney) 1964.
In every job that must be done There is an element of fun You find the fun and snap! The job’s a game
And every task you undertake Becomes a piece of cake A lark! A spree! It’s very clear to see that…. A spoonful of sugar helps the medicine go down The medicine go down, the medicine go down Just a spoonful of sugar helps the medicine go down In a most delightful way
A robin feathering his nest has very little time to rest While gathering his bits of twine and twig Though quite intent in his pursuit He has a merry tune to toot He knows a song will move the job along, for
A spoonful of sugar helps the medicine go down The medicine go down, the medicine go down Just a spoonful of sugar helps the medicine go down In a most delightful way
The honey bee that fetch the nectar From the flowers to the comb Never tired of ever buzzing to and fro Because they take a little nip From every flower that they sip And hence (And hence) They find (They find) Their task is not a grind
“A Spoonful Of Sugar” Mary Poppins (Walt Disney, 1964.
SUCROSE
Introduction
Oral sucrose has been shown to provide effective mild analgesia for minor procedures.
Oral sucrose is most effective for preterm and term neonates (less than 28 days old).
It has also been reported to have some analgesic and calming effects up to 18 months of life.
Preparations
Sucrose 24 % as:
● Oral liquid, 24%, 2 mL, 50, Sucrose Oral Solution
● Oral liquid, 24%, 2 mL, 96, (“Sweet-Ease Natural” - vial)
● Oral liquid, 24%, 15 mL, 200, (“Sweet-Ease Natural” - cup)
● Oral liquid, 24%, 1 mL, 250, (“SweetUms Preserved”, “SweetUms Preservative- Free”).
● Oral liquid, 24%, 1 mL, 100, (“TootSweet”).
While 24% sucrose is most commonly discussed in the literature, a wide range of doses and concentrations have been used.
Sucrose 33 % as:
● Stock bottles (RCH)
10ml of 33% oral sucrose equates to 66 ml of 5% glucose solution.
5% Glucose is the standard oral rehydration solution at RCH.
An infant routinely drinks 70 - 180ml of this concentration per feed.
Chemistry
Sucrose is common table sugar It is a disaccharide of glucose and fructose
Physiology
Pain is a subjective experience.
It has been described in the formal definition, “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”. (www.iasp-pain.org).
Note that the inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment.
Mechanism of action
The mechanism of action is thought to be an orally mediated increase in endogenous opioids.
Pharmacodynamics
The greatest analgesic effect occurs when sucrose is administered approximately 2 minutes before the painful stimulus.
The peak effect appears to occur at 2 minutes. 3
The analgesic effects of sucrose last around 5-8 minutes, following oral administration
Oral sucrose is most effective for preterm and term neonates (less than 28 days old).
It has also been reported to have some analgesic and calming effects up to 18 months of life.
Research supports that sucrose given orally, for procedural pain management within the recommended dosing, does not alter blood sugar levels.
Pharmacokinetics
Absorption:
● Sucrose is administered orally.
Sucrose only effective if given orally. It must be placed on the tongue
Do not give sucrose via nasogastric/orogastric tubes. There is no analgesic effect if sucrose is given directly into the stomach via a nasogastric tube.
Distribution:
● Glucose is distributed throughout the entire body water.
Metabolism:
● Sucrose is metabolized to glucose and fructose.
● Glucose can be:
♥ Used an energy source via glycolysis, the Krebs cycle, and oxidative phosphorylation.
♥ Converted to the storage form glycogen (principally in muscle and liver cells).
Indications
Oral sucrose is indicated for mild analgesia in minor procedures in infants and children up to 18 months:
Suitable procedures include:
1. Immunisations
2. Blood tests/ heel prick tests.
3. IV lines
4. Removal of sutures
5. IM/ SC injections
6. IDC insertion
7. Dressings
8. Adhesive tape 9. Lumbar puncture
Oral sucrose may also be used as a bridge for infants in distress to be examined and to assess the cause of inconsolability. However, support measures should precede oral sucrose administration.
Contraindications/ Precautions
These include:
1. Some monosaccharides/ disaccharide intolerances:
● Sucrose intolerance
● Fructose intolerance
● Glucose-galactose malabsorption
2. Oral sucrose is not appropriate for the management of continuing pain or distress
3. Mothers on methadone:
● Neonates and infants of mothers taking methadone may have altered endogenous opiate responsiveness, resulting in a lack of analgesic effect of oral sucrose in the first days to weeks of life.
It is important to assess the effectiveness of oral sucrose in these infants and to use alternative comfort measures until the infants' endogenous opiate system normalizes.
Adverse effects
GIT upset may occur if sucrose is given to infants with sucrose/fructose intolerance or glucose-galactose malabsorption.
The ongoing use of sucrose in infants with prolonged hospitalizations requiring many doses of sucrose over time for multiple painful procedures has been shown to be safe and effective.
There is no evidence to show that oral sucrose affects future teeth development.
Dosing Sucrose is only effective if given orally.
It must be placed on the anterior tongue
Do not give sucrose via nasogastric/orogastric tubes.
While 24% sucrose is most commonly discussed in the literature, a wide range of doses and concentrations have been used, and individual institutions vary in the concentrations used.
Follow local protocols where available.
Method:
Use a narrow gauge syringe to measure the total dose required
Drop one-quarter (or less) of this onto the anterior of the tongue 2 minutes before starting the procedure, then give the rest of the dose incrementally throughout the procedure as required.
Also offer a dummy if the infant is able to suck - sucrose may be more effective if given with a dummy as the dummy promotes non-nutritive sucking which also contributes to calming.
RCH supplies oral sucrose 33%, however the same dosage regimes are also used for the various 24 % preparations.
A suggested regime is as follows: 1
ORAL SUCROSE ADMINISTRATION
Corrected age * < 32 weeks ≥ 32 weeks to Neonates Infants term 0 -1 month 1 - 18 months Suggested 0.05 mls 0.05 - 0.1 ml 0.05 - 0.1 mls 0.25 - 0.5 mls incremental doses 0.2 mls 0.2 - 0.5 mls 0.2 - 1 ml 1-2 mls Single procedure maximum dose
Suggested 24 1 ml 2.5 mls 5 mls 5 mls (< 3 months) hour maximum dose 10 mls (> 3 months)
* Postmenstrual age is gestational age plus chronological (postnatal) age.
Note that efficacy data in preterm infants < 32 weeks postmenstrual age or infants > 12 months is limited.
If nil by mouth, apply a small amount to the tongue using a mouth swab, as shown
below.
Adjunctive measures are also useful and these include:
1. Full or partial swaddling
2. Cuddling: ● Containment and minimising infant limb flailing, comforts the infant and also allows the parent to have an active role.
3. Kangaroo Care:
● This refers to a neonate lying on the bare skin of their mother (or father) upright at a 40 - 60 degree angle and covered by parent’s shirt/ gown with a n additional blanket as required.
3. Distraction (in older infants)
Alternatives to oral sucrose:
Breast Milk and breastfeeding where available is an alternative - the sweet taste of breast milk also has an analgesic effect and parental contact provides additional maternal comfort.
Other sweet solutions (e.g. glucose) have also been used.
References
1. Sucrose 33% in RCH Clinical Guidelines, Website, July 2018.
2. Sucrose 24% in Australian Medicines Handbook, Website, Accessed April 2017.
3. RWH Neonatal Medicines Formulary Consensus Group, February 2017.
Dr J. Hayes Acknowledgments: Professor Julie Considine Reviewed October 2019.