Literature Review: Oral Sucrose for Infant Immunization

This literature review analyzes the study by Yilmaz et al. (2014) on the efficacy of oral sucrose in reducing pain during routine infant immunizations. The study employed a randomized controlled trial with two experimental groups receiving different concentrations of sucrose solution (75% and 25%) and a placebo group. The primary outcome measured was the crying time of the infants. The researchers utilized convenience sampling and analyzed the data using SPSS. The study found that the administration of sucrose significantly reduced crying time, with the 75% solution demonstrating a greater analgesic effect, establishing a dose-response relationship. The review discusses the study's design, sampling methods, data collection, analysis, and results, including the significance of the findings and their generalizability. It also highlights the strengths and weaknesses of the research design and methods, including the potential for bias and confounding factors.

Running head: LITERATURE REVIEW 1
Literature Review
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LITERATURE REVIEW 2
Literature Review
1. Background of the Study
This paper discusses the nominated article for quantitative literature review, “Yilmaz, G.,
Caylan, N., Oguz, M., & Karacan, C. D. (2014). Oral sucrose administration to reduce pain
response during immunization in 16–19-month infants: a randomized, placebo-controlled trial.
European journal of pediatrics, 173(11), 1527-1532. DOI 10.1007/s00431-014-2358-7”
a. Health Issue
The study by Yilmaz et al. (2014) describes the utility of sucrose as an analgesic during routine
vaccination of children aged between 16 and 19 months old. This age coincides with various
vaccinations in various countries with the oral polio vaccine, the pneumococcal vaccine, and the
pentavalent vaccine predominating. The pentavalent vaccine is an intramuscular concoction of
vaccines to five illnesses – whooping cough, diphtheria, tetanus, hepatitis B, and Haemophilus
influenza type B. A common challenge for health providers offering these injectable vaccines is
the incorporation of children due to the pain.
b. Results of Previous Studies
Reducing pain has, therefore, been an important research agenda in this area (Shah et al., 2009).
Many pharmacological and non-pharmacological modalities of reducing pain have been
investigated over the years. In the past, research found that sucrose has analgesic properties.
c. Significance of Current Study
Various previous studies confirmed the efficacy of sucrose as a viable option for reducing pain
in neonates receiving various injectable vaccines (Hartfield et al., 2008). Yilmaz et al. (2014) set
out to determine the efficacy of sucrose in older children.

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2. Research Design
a. Aim of Study
Yilmaz et al. (2014) looked to determine whether 2 ml of either 75% or 25% sucrose solution
could reduce the pain that children receiving injectable vaccines experienced; the researchers
used the infant crying time as a scale for the pain.
b. Research Design
To achieve their objective, the researchers utilized a randomized controlled trial with placebo
treatment. A randomized controlled study is the highest level of evidence in any research (Lewin
et al., 2009).
c. Its Characteristics
Such studies are able to establish causal relationships and the putative sequence between
variables that suggest causality (Lewin et al., 2009). The researchers in this study utilized two
experimental groups with different dose exposure to demystify the impact of increased dosage on
the subjects.
d. Its Relevance to the Aim of Study
They concluded that the experimental group that was exposed to 75% sucrose solution had lesser
crying time than the one exposed to 25% sucrose hence confirming that sucrose was an effective
analgesic that exhibited a dose-response effect.
3. Sampling
a. Participants - The researchers recruited 694 children aged between 16 and 19 months for
the study. Of the group, they analyzed 527 children.
b. Inclusion Criteria

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The children included in the study were otherwise healthy children who came to the pediatric
department for routine check-ups or immunizations. Only children who were born at term with
normal birth weight were also included in the study (Yilmaz et al., 2015).
c. Importance of Inclusion Criteria
The inclusion criteria were meant to effectively deal with any confounding factors. The entire
group of suitable participants made the sampling frame.
d. Sampling Technique
The researchers used a convenience sampling technique. Using this technique they recruited any
child who came to the pediatrics department during the duration of the study; they would then
include the child in the study once they got consent to do so from the parent or guardian. After
inclusion, they would then randomize the child to the three experimental groups.
e. Appropriateness of the Sample
However, convenience sampling is a major weakness of this study. This sampling method is a
non-probability sampling technique (Emerson, 2015). Like the other non-probability sampling
techniques, these technique increases the chance that researcher bias could interfere with the
selection of participants and hence largely influence the results (Farrokhi & Mahmoudi-
Hamidabad, 2012). In addition, this technique allows numerous confounding factors to be part of
the study and thus heavily interfere with the sampling process and hence the study findings
(Etikan et al., 2016).
4. Data Collection
a. Data Collection
Once a child was included in the study, the nurse practitioner administering the vaccine would
use routine soothing techniques to comfort the child before the procedure.

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b. Role of the Researcher in the Process
The researchers would then note any administration of pre-procedure acetaminophen as it is an
important confounding factor (Yilmaz et al., 2014). Thereafter, the nurse would administer the
test solution and wait for 15 seconds before administering the intramuscular injections of various
vaccines and the oral polio vaccine simultaneously. The expected outcome, which the
researchers then measured, was the crying time of the child. To enhance blinding and eliminate
bias, a pediatrician recorded the crying time and filled the CHEOPS acute pain response form.
c. Appropriateness of Data Collection Method
Considering the nature of the study, this was the best data collection technique. Although
observation of crying time could have its faults, the researcher defined the time that the
pediatrician would measure strictly hence giving them a proper guide (Voepel-Lewis et al.,
2010).
d. Advantages and Disadvantages of the Data Collection Method
However, human error is an important confounding factor. The accuracy of the stopwatches that
the researcher utilized is also an important confounding factors that can easily interfere with the
results of the study and their interpretation. On the better side, the blinding that the researcher
instituted enhances the accuracy of the results of the study and helps to mitigate the impact of
bias. The researchers utilized a double-blind control trial. The nurse practitioner administering
the solution was not aware of the components of the solution she was offering as the solutions
were randomized. The pediatrician collecting the data was also not aware of the components of
the solution that the participant had received. Hence, the human bias of both the nurse
practitioner and the pediatrician could not interfere with the research findings.

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e. Alternative Data Collection Methods
Considering the requirements of the study, observation was the best data collection modality.
The researchers’ decision to utilize the CHEOPS acute pain response form, an effective pain
response data collection form, enhanced the validity of the study (Voepel-Lewis et al., 2010).
However, observation as a data collection method is subject to heavy bias from the researchers.
5. Data Analysis and Results
a. Methods of Data Analysis
The researchers used SPSS 16.0 for Windows as their main tool of statistical data analysis. They
also utilized an analysis of variance (ANOVA) test to differentiate between two variables. They
use a chi-square to determine and differentiate rates in various sets of data. They also utilized
binary logistic regression analysis to determine independent variables and their influence on the
dependent variables.
b. Appropriateness of the Data Analysis Methods
Considering the nature of the data they had, SPSS was the best statistical analytic tool that they
could use. SPSS also offered additional advantages as it is cheap to install, easy to use, and
compatible with many gadgets (Carver & Nash, 2012). The other strategies that the researchers
utilized to analyze the data were also crucial to the determination of the statistical significance of
the data.
c. Rigor of Data Analysis and–
The researcher found that their results were highly valid, reliable, and statistically significant.
Thus, the results of the study were generalizable to the study population.

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d. Significance of Results
The study found out that the administration of sucrose significantly reduced the crying time of
infants aged between 16 and 19 months during routine immunizations with intramuscular
vaccines (Yilmaz et al., 2014). The fact that the crying time was far less for children given 75%
sucrose compared to those given 25% sucrose confirmed the analgesic properties of sucrose and
established that these properties showed a dose-response.
e. Other Settings for Generalization
Considering that previous studies had demonstrated the analgesic properties of sucrose for
neonates, the results of this study are generalizable for children of all ages (Hatfield, 2008). It
might even be possible to utilize sucrose as an analgesic in other painful situations rather than
vaccination.

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References
Carver, R. H., & Nash, J. G. (2012). Doing data analysis with SPSS: Version 18. Australia:
Brooks/Cole Cengage Learning.
Emerson, R. W. (2015). Convenience sampling, random sampling, and snowball sampling: How
does sampling affect the validity of research?. Journal of Visual Impairment & Blindness
(Online), 109(2), 164.
Etikan, I., Musa, S. A., & Alkassim, R. S. (2016). Comparison of convenience sampling and
purposive sampling. American Journal of Theoretical and Applied Statistics, 5(1), 1-4.
doi: 10.11648/j.ajtas.20160501.11
Farrokhi, F., & Mahmoudi-Hamidabad, A. (2012). Rethinking convenience sampling: Defining
quality criteria. Theory and practice in language studies, 2(4), 784.
doi:10.4304/tpls.2.4.784-792
Hatfield, L. A. (2008). Sucrose decreases infant biobehavioral pain response to immunizations: a
randomized controlled trial. Journal of nursing scholarship, 40(3), 219-225.
https://doi.org/10.1111/j.1547-5069.2008.00229.x
Hatfield, L. A., Gusic, M. E., Dyer, A. M., & Polomano, R. C. (2008). Analgesic properties of
oral sucrose during routine immunizations at 2 and 4 months of age. Pediatrics, 121(2),
e327-e334.
Lewin, S., Glenton, C., & Oxman, A. D. (2009). Use of qualitative methods alongside
randomised controlled trials of complex healthcare interventions: methodological study.
Bmj, 339, b3496. doi: https://doi.org/10.1136/bmj.b3496
Shah, V., Taddio, A., & Rieder, M. J. (2009). Effectiveness and tolerability of pharmacologic
and combined interventions for reducing injection pain during routine childhood

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immunizations: systematic review and meta-analyses. Clinical therapeutics, 31, S104-
S151. DOI: https://doi.org/10.1016/j.clinthera.2009.08.001
Voepel-Lewis, T., Zanotti, J., Dammeyer, J. A., & Merkel, S. (2010). Reliability and validity of
the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in
critically ill patients. American journal of critical care, 19(1), 55-61.
doi:10.4037/ajcc2010988
Yilmaz, G., Caylan, N., Oguz, M., & Karacan, C. D. (2014). Oral sucrose administration to
reduce pain response during immunization in 16–19-month infants: a randomized,
placebo-controlled trial. European journal of pediatrics, 173(11), 1527-1532. DOI
10.1007/s00431-014-2358-7