Introduction
Scientific evidence suggests substantial health benefits of male circumcision. The procedure, however, is painful and appropriate analgesia is always required. There’s an increasing need for clinicians to selectively administer an effective analgesic to alleviate such pain. Evidence shows that infants who are circumcised without the administration of an appropriate analgesic, undergo physiologic pain and stress (Fitzgerald & Walker, 2009).
Negative physiological stress responses, where the infants experience enhanced pain response during immunizations that follow circumcision, have also been demonstrated (Harrison et al, 2009). The research is aimed at increasing knowledge about the impact of using either of the two analgesics on efficiency, side effects, and patient preferences. The findings will enable medical practitioners to offer appropriate advice and make the best choice of an analgesic during circumcision
- Research question: Which is the best method of pain management during circumcision: EMLA Cream or sucrose?
- Hypothesis: Sucrose is a better analgesic for use in circumcision than EMLA cream
Literature Review
Sucrose has been found to relieve pain in medical procedures carried on both term and preterm neonates. Several scientific societies recommend its use in these procedures. It has been shown to have minimal post-exposure effects (Taddio et al, 2008). Twenty studies in a recent Cochrane systematic review involving preterm neonates, prove the efficacy of sucrose as an analgesic. It is, however, moderate and may require boosting with other milder analgesics. Cochrane review points out that sucrose is quite effective for pain alleviation in expectant women two days before child delivery. The combination of sucrose with any other appropriate analgesia for procedural pains is recommended. Substitutive therapy is also suggested to relieve the pains.
About the use of EMLA cream as an analgesic in neonates, the studies that have been done have produced conflicting results. The analgesic was shown to be less efficacious (Marcatto et al, 2009) in research where several infants aged 26 to 33 were examined. The study was double-blind and also had stringent placebo controls in place. The study revealed that EMLA cream was not more efficacious than a placebo cream.
The responses measured were both behavioral and physiologic. In term neonates, oral glucose was shown to serve as better analgesia compared to EMLA in alleviating venipuncture. Oral glucose is also topically administered for a variety of medical procedures (Pasek & Huber, 2012). EMLA has also been found to pose substantial health risks to some neonates through its side effects. It has the possibility of it increasing the levels of methemoglobin (Nascimento et al, 2008).
Sucrose is an effective analgesic in venipuncture and reduces the heart rate (Marcatto et al, 2009). Oxygen saturation has been found to decline with its use. Its efficacy in bladder catheterization and other very painful procedures is low unless complemented with another analgesic (Harrison et al, 2008). The reviewers recommend this analgesic in half-a-milliliter to two-milliliter portions for infants. The administration of sucrose in these portions has been proved to be safe and has no substantial side effects (Harrison et al, 2010).
Method
The participants will be 500 neonates who are below 35 weeks of post-gestational age. The analgesics understudy will be administered to them in normal and currently acceptable conditions of administering routine injections. The procedure will be conducted in a hospital setting over a period within which the targeted sample can be attained.
Sampling
The selection of subjects will be done based on tolerance to the component substances of the analgesics. Neonates who may not tolerate either of the analgesics will be completely excluded from the sample. Sampling will be random and only tolerant neonates whose parents are compliant will be included in the sample.
Research Design
A randomized study to be carried out will include children who are below 35 weeks of age. Randomization of the study helps to reduce bias (Whittemore et al, 2009). During normal procedural injections, the neonates will be given accepted dosages of either of the analgesics. Cases, whereby any other analgesic is preferred, will be exempted from the study to conform to medical research ethics. A consideration of the parents’ preference for either of the analgesics will be made. The neonates who legitimately fall within the sample will each receive either sucrose or EMLA cream before a gentle skin penetration is made using a sterile needle.
Data Collection
Videotapes of the punctures are to be taken for use in quantifying pain. The Douleur Aiguë Nouveau-né behavioral scale, also known as the DAN scale, will be used in this procedure. Pain will then be assessed on this scale for the period during the puncture and after it but before the subject recovers fully. The second period may take up to 40 seconds after the needle has been removed from the skin. A comparison shall then be made for pain scores over time and for scores observed between the punctures. A repeated-measures analysis of variance should be used for the latter comparison.
Measures: The principal measure of outcome will be the DAN behavioral scale pain units. Patient preference will also be recorded.
The bias that may arise from altered pain responses as a result of possible side effects of previously administered analgesics, will be curbed by excluding the affected subjects from the sample. Previous analgesic exposure will be ascertained from information relayed by medical records of the neonates and from that given by the parents.
References
Cochrane Collaboration. (2010). Sucrose for analgesia in newborn infants undergoing painful procedures (Review) 110. JohnWiley & Sons Publishers Ltd.
Fitzgerald, M., & Walker, S. (2009). Infant pain management: a developmental neurobiological approach, Neurology, 5(1) 35-50.
Harrison, D., Loughnan, P., Manias, E., Gordon, I., & Johnston, L. (2009). Repeated doses of sucrose in infants continue to reduce procedural pain during prolonged hospitalizations. Nursing Research, 58 (6), 427-434.
Harrison, D.M. et al. (2008). Oral sucrose for pain management in infants: Myths and misconceptions, Journal of Neonatal Nursing, 14 (2), 39-4.
Harrison, D., Stevens, B., Bueno, M., Yamada, J., Yamada, J., Adams-Webber, T., Beyene, J., & Ohlsson, A. (2010). Efficacy of sweet solutions for analgesia in infants between 1 and 12 months of age: A systematic review. Archives of Disease in Childhood, 95, 406-413.
Marcatto J.O, Tavares E.C, Silva Y.P. (2009). Topical anesthesia in preterm neonate: a reflection on the underutilization in clinical practice, 71-72.
Pasek, T.A., & Huber, J.M. (2012). Hospitalized infants who hurt: a sweet solution with oral sucrose. American Association of Critical Care Nurse, 32(1), 61-69.
Taddio, A., Shah, V., Hancock, R., Smith, R., Stephens, D., Atenafu, E…Beyene, J. (2008). Effectiveness of sucrose analgesia in newborns undergoing painful medical procedures. Canadian Medical Association Journal, 179(1), 37-43.
Nascimento TS, Pereira ROL, Mello HLD, Costa J. (2008). Metemoglobinemia: do diagnósticoao tratamento. Rev Bras Anestesiol, 58(6):651-64.
Whittemore, R., Grey, M., & Singh, M. (2009). Chapter 10: Experimental and quasiexperimental designs. Nursing Research in Canada, (2), 210-228). Toronto: Mosby Elsevier.