Original articleThe use of breast-feeding for pain relief during neonatal immunization injections
Introduction
Routine immunization injections are the most common painful procedures in childhood. Most of these injections are administered early in a child's life (American Academy of Pediatrics Committee on Infectious Diseases, 2003). Unfortunately, despite the increased focus on pain assessment and management, infant injection-related pain remains to be largely untreated. Untreated pain has immediate and measurable negative effects, most notable of which are child distress and parent distress (Reis, Roth, Syphan, Tarbell, & Holubkov, 2003). Preliminary data suggest that untreated pain early in life may also cause deleterious effects on the developing central nervous system (Gradin et al., 2002, Logan, 1999, Ors et al., 1999, Taddio et al., 1995, Taddio et al., 1999). Taddio, Katz, Ilersich, and Koren (1997) showed that newborns circumcised without anesthesia exhibited significantly greater pain responses with vaccination 4 months later as compared with infants who were not circumcised. Similarly, intermittent pain can permanently affect limbic catecholamine levels and reactions to situational or pharmacologic stressors in animal models (Kehoe, Clash, Skipsey, & Shoemaker, 1996). The claim that newborn pain is only temporary and current can no longer be made. The number of painful stimuli needs to be kept at a minimum, and every effort should be made to render these stimuli less painful. Many successful approaches to pain management use pharmacologic and nonpharmacologic strategies. Various simple methods have been shown to effectively reduce the pain response of newborns undergoing routine procedures, such as heel lancing. Swaddling, holding, and providing the oral tactile stimulation of sucking on a pacifier are effective nonpharmacologic approaches (Campos, 1994, Gormally et al., 2001, Johnston & Strada, 1986). Recent studies have reported that pain can be reduced with simple and benign interventions such as sweet oral solutions (sucrose or glucose) and nonnutritive suckling (Blass & Watt, 1999, Carbajal et al., 1999, Skogsdal et al., 1997, Stevens et al., 2001), breast-feeding (Carbajal, Veerapen, Couderc, Jugie, & Ville, 2003), and multisensory stimulation (Bellieni et al., 2002).
Breast-feeding links evolutionary biology and medical practice. This is of clinical interest because pain is routinely experienced in hospital settings, even by healthy newborns, and natural interventions are effective at a time when many pharmacologic interventions are not (Blass & Barr, 2000, Gray et al., 2002). There are several studies showing that breast milk orosensorially affects pain response (Carbajal et al., 2003, Gray et al., 2002). It has been reported that breast-feeding also involves all natural ways of relieving pain, such as skin-to-skin contact, suckling, as well as milk and sweet taste (Gray et al., 2002).
Recent studies have demonstrated that certain tastes and flavors alleviate newborn pain. As little as 2 ml of milk, with its fat and protein components (Blass, 1997a, Blass, 1997b) and sweet substances, reduces pain in human and rat infants and eliminates spontaneous crying (Carbajal et al., 1999, Haouari et al., 1995, Overgaard & Knudsen, 1999, Ramenghi et al., 1999, Stevens et al., 2001). Moreover, in rats, the mechanisms underlying these taste-induced analgesics are opioid mediated (Blass & Fitzgerald, 1988, Blass et al., 1990, Blass et al., 1987, Shide & Blass, 1989) and block pain afferents at the level of the spinal cord. Nonnutritive suckling itself is also an antinociceptive in rat and human infants (Blass & Watt, 1999, Campos, 1994), and suckling experience is not required for its manifestation (Blass & Hoffmeyer, 1991). Nociception is defined as the sum of a mixed series of electrochemical events that occur between tissue damage and pain perception (Guyton, 1995). More recently, Gray, Watt, and Blass (2000) reported that 10–15 minutes of skin-to-skin contact between mothers and infants reduced crying, grimacing, and heart rate during heel lance procedures. In their study, contact alone, in the absence of suckling, dulled pain reactivity (Gray et al., 2000). Specifically, crying and grimacing are markedly reduced during blood collection in newborns who are held by their mothers in full-body contact (Gray et al., 2000). Such contact also blocks the substantial increase in heart rate that normally accompanies blood collection (Gray et al., 2000). Corff, Seideman, Venkataraman, Lutes, and Yates (1995) reported that cuddling infants and holding their extremities closely in flexion during heel lancing decrease heart rate, shorten length of crying, and correct sleep–wakefulness periods after the procedure. Fitzgerald, Millard, and Macintosh (1988) also found that tactile and vocal stimulations during heel lancing decreased physiologic stress. Feldman and Eidelman (2003) reported that skin-to-skin contact with newborns helped them adapt better to changes in the environment. Choonara (1999) reported that parents know that crying infants need to be comforted and that they hold close, cuddle, and, even when not hungry, breast-feed their infants to comfort them.
The pain reduction methods used, including the use of the nonpharmacologic approaches of oral tactile stimulation and holding, are theorized to act via the activation of endogenous opioid pathways (Reis et al., 2003, Wong et al., 1999). Because breast-feeding probably is the most potent pleasant stimulation that a newborn infant can experience, we hypothesized that breast-feeding could have analgesic properties in neonates.
The purpose of this study was to unite the different components of breast-feeding (taste, suckling, and skin-to-skin contact), which have been shown to be individually analgesic, by allowing newborns to suckle from their nursing mothers before, during, and after an immunization procedure. The efficacy of this intervention was determined by evaluating audiotaped recordings of infants crying and by assessing blockade of heart rate increases and oxygen saturation decreases that normally accompany the immunization. The hypothesis tested was that breast-feeding would decrease the length of crying time, prevent an increase in heart rate, and prevent a decrease in oxygen saturation during vaccination as compared with the control condition (i.e., no breast-feeding). We explored the clinical efficacy of breast-feeding as an analgesic in the immunization clinic as a supplement to the natural practice of infant soothing practiced by the parents and single nurse practitioner.
Section snippets
Design
The study, which was a prospective and controlled trial, was performed with neonates who were brought to the Healthy Child Clinic of the Akdeniz University Medical Faculty between June 1, 2001, and July 31, 2002. In the intervention group (n = 33), infants were breast-fed before, during, and after their immunization. The control infants (n = 33) were swaddled in their bassinets during the procedure (standard clinic procedure).
Sampling
After mothers had given their written informed consent to be included
Demographic characteristics
Sixty-six infants were enrolled in this study: 33 in the experimental (breast-feeding) group and 33 in the control group. The mean age of the breast-feeding infants was 2.8 ± 1.1 months, whereas that of the control infants was 3.1 ± 1.3 months. Table 1 shows details on how the infants were distributed between the breast-feeding group and the control group. Most of the breast-feeding and control infants were delivered via a cesarean section (n = 23 and n = 24, respectively), with no
Discussion
Giving immunizations by injection is essential in the provision of primary care to infants, but it is also a distressing experience for them. This was confirmed by our study. The fat, protein, and other ingredients of breast milk stimulate opioids and block pain fibers running down to the spinal cord, which may be the reason why suckling has an antinociceptive effect (Gray et al., 2002).
We detected a reduction in response to pain among infants who were breast-feeding before, during, and after
Implications for practice
Reducing pain during immunization injections in infants is very challenging. To be adopted by busy neonatal practices, pain management approaches must be simple, convenient, fast acting, inexpensive, and effective. Some simple pain reduction methods that have been previously described, such as nonnutritive suckling, sucrose administration, parental holding, and breast-feeding, are effective in relieving pain in infants. This study demonstrates that breast-feeding is associated with reduced
Limitations
We demonstrated that an intervention combining breast-feeding, skin-to-skin contact, and holding is an effective method for controlling the incidence of crying, heart rate, and oxygen saturation in 2-, 3-, or 4-month-old infants receiving an injection. The generalization of this study's findings is limited by the administration of a single injection. The efficacy of our approach needs to be investigated in the setting of multiple injections, which young infants typically receive in most
Conclusions
Breast-feeding and the component parts of taste, suckling, and contact are associated with significantly reduced crying time in young infants during immunization injections. In addition, this immunization injection technique was found to be very easy for nurses to put it into practice. This simple, effective, and feasible intervention is also popular among parents and can readily be incorporated into the practice of standard infant immunization.
Acknowledgments
This study received external funding from the Akdeniz University Scientific Research Project Unit.
We are grateful to all the parents who participated in this study.
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