Analgesic efficacy and safety of morphine in the Procedural Pain in Premature Infants (Poppi) study: randomised placebo-controlled trial

Caroline Hartley, Fiona Moultrie, Amy Hoskin, Gabrielle Green, Vaneesha Monk, Jennifer L Bell, Andrew R King, Miranda Buckle, Marianne van der Vaart, Deniz Gursul, Sezgi Goksan, Edmund Juszczak, Jane E Norman, Richard Rogers, Chetan Patel, Eleri Adams, Rebeccah Slater

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Abstract

Summary
Background
Infant pain has immediate and long-term effects but is undertreated because of a paucity of evidence-based analgesics. Although morphine is often used to sedate ventilated infants, its analgesic efficacy is unclear. We aimed to establish whether oral morphine could provide effective and safe analgesia in non-ventilated premature infants for acute procedural pain.

Methods
In this single-centre masked trial, 31 infants at the John Radcliffe Hospital, Oxford, UK, were randomly allocated using a web-based facility with a minimisation algorithm to either 100 μg/kg oral morphine sulphate or placebo 1 h before a clinically required heel lance and retinopathy of prematurity screening examination, on the same occasion. Eligible infants were born prematurely at less than 32 weeks' gestation or with a birthweight lower than 1501 g and had a gestational age of 34–42 weeks at the time of the study. The co-primary outcome measures were the Premature Infant Pain Profile–Revised (PIPP-R) score after retinopathy of prematurity screening and the magnitude of noxious-evoked brain activity after heel lancing. Secondary outcome measures assessed physiological stability and safety. This trial is registered with the European Clinical Trials Database (number 2014-003237-25).

Findings
Between Oct 30, 2016, and Nov 17, 2017, 15 infants were randomly allocated to morphine and 16 to placebo; one infant assigned placebo was withdrawn from the study before monitoring began. The predefined stopping boundary was crossed, and trial recruitment stopped because of profound respiratory adverse effects of morphine without suggestion of analgesic efficacy. None of the co-primary outcome measures differed significantly between groups. PIPP-R score after retinopathy of prematurity screening was mean 11·1 (SD 3·2) with morphine and 10·5 (3·4) with placebo (mean difference 0·5, 95% CI −2·0 to 3·0; p=0·66). Noxious-evoked brain activity after heel lancing was median 0·99 (IQR 0·40–1·56) with morphine and 0·75 (0·33–1·22) with placebo (median difference 0·25, 95% CI −0·16 to 0·80; p=0·25).

Interpretation
Administration of oral morphine (100 μg/kg) to non-ventilated premature infants has the potential for harm without analgesic efficacy. We do not recommend oral morphine for retinopathy of prematurity screening and strongly advise caution if considering its use for other acute painful procedures in non-ventilated premature infants.

Funding
Wellcome Trust and National Institute for Health Research.
Original languageEnglish
Pages (from-to) 2595-2605
Number of pages11
JournalLancet
Volume392
Issue number10164
Early online date30 Nov 2018
DOIs
Publication statusPublished - 15 Dec 2018

Bibliographical note

Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.

Keywords

  • Administration, Oral
  • Analgesics, Opioid/administration & dosage
  • Bradycardia/chemically induced
  • Female
  • Gestational Age
  • Humans
  • Infant, Extremely Low Birth Weight
  • Infant, Newborn
  • Infant, Premature
  • Infant, Premature, Diseases/therapy
  • Male
  • Morphine/administration & dosage
  • Oxygen Consumption/drug effects
  • Pain Measurement
  • Pain, Procedural/drug therapy
  • Single-Blind Method
  • Tachycardia/chemically induced
  • Treatment Failure

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