NIHR Signal Breastfeeding reduces crying during baby immunisation

Published on 21 February 2017

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.

Breastfeeding reduces crying during baby immunisation

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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, pacifiers, 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.

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, pacifiers, 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.

Breastfeeding for procedural pain in infants beyond the neonatal period

Published on 30 October 2016

Harrison, D.,Reszel, J.,Bueno, M.,Sampson, M.,Shah, V. S.,Taddio, A.,Larocque, C.,Turner, L.

Cochrane Database Syst Rev Volume 10 , 2016

BACKGROUND: Randomised controlled trials (RCTs) show that breastfeeding newborn infants during painful procedures reduces pain. Mechanisms are considered to be multifactorial and include sucking, skin-to-skin contact, warmth, rocking, sound and smell of the mother, and possibly endogenous opiates present in the breast milk. OBJECTIVES: To determine the effect of breastfeeding on procedural pain in infants beyond the neonatal period (first 28 days of life) up to one year of age compared to no intervention, placebo, parental holding, skin-to-skin contact, expressed breast milk, formula milk, bottle feeding, sweet-tasting solutions (e.g. sucrose or glucose), distraction, or other interventions. SEARCH METHODS: We searched the following databases to 18 February 2016: the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE including In-Process & Other Non-Indexed Citations (OVID), Embase (OVID), PsycINFO (OVID), and CINAHL (EBSCO); the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov (clinicaltrials.gov), and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) (apps.who.int/trialsearch/) for ongoing trials. SELECTION CRITERIA: We included RCTs and quasi-RCTs involving infants aged 28 days postnatal to 12 months and receiving breastfeeding while undergoing a painful procedure. Comparators included, but were not limited to, oral administration of water, sweet-tasting solutions, expressed breast or formula milk, no intervention, use of pacifiers, positioning, cuddling, distraction, topical anaesthetics, and skin-to-skin care. Procedures included, but were not limited to: subcutaneous or intramuscular injection, venipuncture, intravenous line insertion, heel lance, and finger lance. We applied no language restrictions. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data. The main outcome measures were behavioural or physiological indicators and composite pain scores, as well as other clinically important outcomes reported by the authors of included studies. We pooled data for the most comparable outcomes and where data from at least two studies could be included. We used mean difference (MD) with 95% confidence interval (CI), employing a random-effects model for continuous outcomes measured on the same scales. For continuous outcomes measured on different scales, we pooled standardised mean differences (SMDs) and associated 95% CIs. For dichotomous outcomes, we planned to pool events between groups across studies using risk ratios (RRs) and 95% CIs. However, as insufficient studies reported dichotomous outcomes, we did not pool such events. We assessed the evidence using GRADE and created a 'Summary of findings' table. MAIN RESULTS: We included 10 studies with a total of 1066 infants. All studies were conducted during early childhood immunisation. As the breastfeeding intervention cannot be blinded, we rated all studies as being at high risk of bias for blinding of participants and personnel. We assessed nine studies as being at low risk of bias for incomplete outcome data. In addition, we rated nine studies as high risk for blinding of outcome assessment. We scored risk of bias related to random sequence generation, allocation concealment, and selective reporting as unclear for the majority of the studies due to lack of information.Our primary outcome was pain. Breastfeeding reduced behavioural pain responses (cry time and pain scores) during vaccination compared to no treatment, oral water, and other interventions such as cuddling, oral glucose, topical anaesthetic, massage, and vapocoolant. Breastfeeding did not consistently reduce changes in physiological indicators, such as heart rate. We pooled data for duration of cry from six studies (n = 547 infants). Breastfeeding compared to water or no treatment resulted in a 38-second reduction in cry time (MD -38, 95% CI -50 to -26; P < 0.00001). The quality of the evidence according to GRADE for this outcome was moderate, as most infants were 6 months or younger, and outcomes may be different for infants during their 12-month immunisation. We pooled data for pain scores from five studies (n = 310 infants). Breastfeeding was associated with a 1.7-point reduction in standardised pain scores (SMD -1.7, 95% CI -2.2 to -1.3); we considered this evidence to be of moderate quality as data were primarily from infants younger than 6 months of age. We could pool heart rate data following injections for only two studies (n = 186); we considered this evidence to be of low quality due to insufficient data. There were no differences between breastfeeding and control (MD -3.6, -23 to 16).Four of the 10 studies had more than two study arms. Breastfeeding was more effective in reducing crying duration or pain scores during vaccination compared to: 25% dextrose and topical anaesthetic cream (EMLA), vapocoolant, maternal cuddling, and massage.No included studies reported adverse events. AUTHORS' CONCLUSIONS: We conclude, based on the 10 studies included in this review, that breastfeeding may help reduce pain during vaccination for infants beyond the neonatal period. Breastfeeding consistently reduced behavioural responses of cry duration and composite pain scores during and following vaccinations. However, there was no evidence that breastfeeding had an effect on physiological responses. No studies included in this review involved populations of hospitalised infants undergoing other skin-breaking procedures. Although it may be possible to extrapolate the review results to this population, further studies of efficacy, feasibility, and acceptability in this population are warranted.

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