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NIHR Signal Breastfeeding reduces crying during baby immunisation

Published on 21 February 2017

doi: 10.3310/signal-000387

Babies who were breastfed before and during routine childhood immunisations cried on average for 38 seconds less and had lower pain scores compared to babies not breastfed.

This evidence review used data from 10 trials, with results for 1,066 babies, mostly between one and six months old, following their normal immunisation schedule.

Immunisation levels in England are below recommended levels and falling. Pain from injections causes distress to babies and parents, and may put parents off bringing their children for immunisation or finishing the course of treatment over a year.

This is the first review to focus studies of breastfeeding for any painful procedure for older babies. The only trials found related to immunisations, and none was on other procedures.

If breastfeeding by mothers helps reduce babies’ pain, it might be a cost-free way to increase the numbers who complete their full immunisation schedule.

  •   Neonates and neonatal care, Primary care
Breastfeeding reduces crying during baby immunisation

Why was this study needed?

Uptake of most routine childhood immunisations at ages one and two has been falling since 2013 in England. Only 93.6% of babies aged one year and 91.9% aged two years completed all their immunisations in 2015/16, below the World Health Organization target of 95%.

Needles used for childhood immunisation from birth are necessary, but painful. The pain can distress both babies and their carers, and lead to anxiety and fear of needles. This may be a factor in babies not completing their full schedule of immunisation.

There is good evidence that breastfeeding during blood tests reduces pain in newborn babies (up to 28 days old), but the evidence was unclear for older babies. There were no evidence reviews looking at whether breastfeeding might help during painful procedures in babies aged one month to one year.

What did this study do?

This systematic review found 10 trials examining whether breastfeeding during immunisations had any effect on pain. In total, 1,066 babies were included, aged from one to 12 months, although most were aged one to six months. None of the studies were carried out in the UK.

The trials compared infant breastfeeding before and during the injections, with no pain treatment, sugar solutions, distilled water, anaesthetic cream, massage therapy and cold sprays. Different methods were used to measure pain outcomes. These included how long babies cried for, how soon they started crying, pain scales, and reactions such as heart rate.

The trials were relatively small, and it was impossible to blind the mothers or healthcare professionals to which group they were in. But the quality of the evidence overall for crying time and pain scores was graded moderate, suggesting it is reliable.

What did it find?

  • Six studies, with 547 babies in total, showed a reduction in length of time crying in the breastfeeding groups compared to the other groups (mean difference -38 seconds, 95% confidence interval [CI] -50 to -26).
  • Five studies, which included 310 babies, used various pain scores after immunisation to measure pain. Pooling these results showed a reduction in pain scores in the breastfeeding groups compared to the other groups (standardised mean difference -1.7, 95% CI -2.2 to -1.3).
  • Only one study measured heart rate during immunisation, and two measured heart rate after the injections. No differences were found between breastfeeding and other groups. One study measured oxygen saturation during and after immunisation, but found no differences between the breastfeeding and other groups.
  • Eight of the studies included babies aged one to six months. Only two studies included children between six and twelve months. The findings may be different for older children.
  • None of the included studies reported any adverse effects such as choking, gagging, spitting or coughing. No studies reported on the acceptability of breastfeeding, from the mothers’ or healthcare professionals’ perspective. The studies didn't report on the practicalities of breastfeeding in the immunisation clinics.

What does current guidance say on this issue?

The good practice in postoperative and procedural pain management guideline from the Association of Paediatric Anaesthetists of Great Britain and Ireland, published in 2012, recommends that breastfeeding (along with swaddling, paciļ¬ers, and sugar) should be considered for babies being vaccinated.

Public Health England publishes the Green Book, a guide for healthcare professionals about vaccines and vaccination procedures. The chapter on immunisation procedures discusses injection sites and techniques, but does not mention pain management.

What are the implications?

This study reinforces the message that, when mothers are already breastfeeding, it could be a good way to reduce pain during immunisation.

Reduced distress and pain for the babies could encourage mothers to complete their babies’ immunisation programme. This might help raise overall immunisation rates.

Breastfeeding needs no additional equipment or preparation, and involves no additional costs for healthcare providers.  Clinics could consider making dedicated space available to allow women to breastfeed comfortably.

This study did not find any evidence about babies undergoing other painful procedures in hospital settings.

Citation and Funding

Harrison D, Reszel J, Bueno M, et al. Breastfeeding for procedural pain in infants beyond the neonatal period. Cochrane Database Syst Rev. 2016;10:CD011248.

Cochrane UK and the Cochrane Pain, Palliative and Supportive Care Group are supported by NIHR infrastructure funding.

Bibliography

Association of Paediatric Anaesthetists of Great Britain and Ireland. Good Practice in Postoperative and Procedural Pain Management 2nd Edition, 2012. Pediatric Anesthesia. 2012;22(Suppl 1):1-79

NHS Digital. NHS Immunisation Statistics, England – 2015-16.

PHE. Quarterly vaccination coverage statistics for children aged up to five years in the UK (COVER programme): April to June 2016. London: Public Health England; 2016

PHE. Immunisation procedures: the green book, chapter 4. London: Public Health England; 2013.

Expert commentary

Many women chose not to breastfeed and those that do breastfeed often only continue for a few weeks following birth. Therefore, to provide more generalisable evidence that will inform health care providers and most mothers, future trials should compare the mothers chosen method of infant feeding (either breast or artificial) with usual care (or no infant feeding). The question would then be: is ‘infant feeding’ during painful procedures safe and does it reduce signs of pain?

Dr Diane Farrar, NIHR Post-Doctoral Research Fellow and Lead Midwife for Research, Bradford Institute for Health Research