http://doi.org/10.33698/NRF0309-Lovepreet Kaur, Sukhwinder Kaur, Raman Kalia, Bhavneet Bharti
Abstract : Vaccination, an inherent part of the health care delivery system for reducing the
morbidity and mortality due to “vaccine preventable diseases” is also the commonest health related
procedure which children routinely undergo. Injectable vaccines are a common source of pain and
distress for the young children. Pain management in infants is difficult as they cannot verbally
express pain and it is largely a neglected domain. The present study was carried out to assess the
effect of feeding the infant on breast during injecting vaccine on perception of pain intensity among
infants. A total of 216 infants receiving DPT and its combinant vaccines were randomly distributed
into control and experimental group. Infants in the control group (n=106) were administered vaccine
without breast feeding and the infants in experimental group (n=110) were administered vaccine
during breast feeding. Pre-vaccination and post-vaccination behavior of infants was scored on Modified
Behavioral Pain Scale. Cry duration was recorded. The net pain scores and duration of cry was
compared among the two groups. Significant difference in behavioral response of the infants was
observed among the infants, t= 5.5 at df = 214 (p<0.01). It was concluded that the perception of
pain intensity is less among the infants when vaccine is administered during breast feeding.
Correspondence at :
Lovepreet Kaur
National Institute of Nursing Education,
PGIMER, Chandigarh
Key words :
Vaccination among infants, Pain
Introduction
Routine vaccination is an inherent par t
of the health care delivery system as it is the
most effective health intervention in reducing
the morbidity and mor tality due to “vaccine
preventable diseases”.1 Most of the injectable
vaccines are administered early in child’s life2,3
and always lead to some amount of fear to
the parents as well as to the child 4.
Nursing and Midwifery Research Journal, Vol-5, No. 4,October 2009 143
Evidence suppor ts that neonatal pain
experience may have far reaching effects even
up to or beyond school age 5 leading to
psychological sequelae in neonates.6
Repeated pain experiences lead to alterations
in thermal pain responsivity characterized by
enhanced perceptual sensitization to
prolonged painful stimulation, hypoalgesia to
brief heat pain stimuli and activity-induced
changes in the functioning of pain pathways
that persist well beyond infancy.7 Painful
experience can have immediate, shor t term,
long term physiological and behavioral effects
in infants. 5,6 ,8,9.
Greater nociceptor nerve ending’s
density and shor ter interneuron and
neuromuscular distances in neonates nullify
the belief that the human newborns do not
experience pain though they may not be able
to vocalize it.5, 6, 9, 10,11 Infact infant’s
temperament, age, previous painful
experience exer t positive influence on pain
perception while gender, position don’t effect
the same.6,11-14 The injection technique, an
impor tant parameter in ensuring sufficient
vaccine delivery especially the WHO injection
technique of stretching the skin between
finger and thumb reduces local reactions and
less pain if given rapidly without aspiration
and rapid withdrawal.15-18 Needle measuring 23
gauze is recommended in child immunization.
19 -23
Infants respond to painful stimuli
variably.24 Parent coping-promoting
vocalizations have a stronger effect on infant
pain responses. 25 Growing concerns about
pain management in newborns and infants
have raised some critical questions about the
accuracy of assessment of acute and
procedural pain scales in clinical settings.
However, the accuracy of these scales is still
questionable.26,27 Behavior observation is also
beneficial and valuable for non-verbal age
group 28, 29,30,31. Correct pain assessment by the
nurses that is essential in planning and
implementation of the pain management
strategies.11, 32 Physiological measures of the
pain response require complex apparatus for
evaluation thus a combination of behavioral
and physiological parameters has been used
by researchers. 33-39
The general tendency among those
caring for young babies is to treat pain after it
has occurred.40 Administering appropriate
doses of analgesics with or without sedatives,
though more humane in nature, sometimes
leads to over or under dosing of the analgesics
as pain can be measured accurately only
when it occurs.41, 42, 43 Non-pharmacologic
therapies including non-nutritive sucking
(NNS) both with and without sucrose,
swaddling or kangaroo care, music therapy
and multi-sensorial stimulation are also
beneficial for pain reduction.41,44, 45
However, repeated use of sucrose
analgesia in infants less than 31 weeks
gestation may put them at risk for poorer
neurobehavioural development and
physiological outcomes in later weeks of life.
46,47 Moreover, the dose of sucrose, methods
of administration vary and the most effective
has not been established yet .43 Non-nutritive
sucking (NNS) on pacifiers reduces the
incidence and duration of crying associated
Nursing and Midwifery Research Journal, Vol-5, No. 4,October 2009 144
with painful experiences of infants.48,49
However, lack of crying can be attributed to
physical incompatibility of having a pacifier
firmly seated in infant’s mouth.45
Breast-feeding links evolutionar y
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.50 There are several
studies showing that breast milk
orosensorially affects pain response. 50, 51
Breast feeding and expressed breast milk is
associated with pleasant memories of being
with mother for babies.52 Breast feeding is
practical as it is easily achievable from the
perspectives of health care providers and
parents par ticularly in the situations where
acute pain experience is there as for example
during blood collections and immunization
injections among the neonates as it effectively
reduces response to pain. 51, 53
More recently, Gray, Watt, and Blass
(2000) repor ted that 10-15 minutes of skinto-
skin contact between mothers and infants
reduced crying, grimacing, and hear t rate
during heel lance procedures. In their study,
contact alone, in the absence of suckling,
dulled pain reactivity.54 Specifically, crying and
grimacing are markedly reduced during blood
collection in newborns that are held by their
mothers in full-body contact.54
The purpose of this study was to assess
the effect of breast feeding on perception of
pain intensity by the infants and to provide
evidence base for pain management in
vaccination room of APC, PGIMER.
Materials and Methods
The quasi-experimental study was
performed with neonates who were brought
to the Vaccination Room of Advanced Pediatric
Center of Post Graduate Institute of Medical
Education and Research (PGIMER),
Chandigarh, between July and August 31,
2008. PGIMER is ter tiary care center (1500
bedded approx) which provides superspecialty
diagnostic, curative and therapeutic
health care services to nor thern India. APC
is exclusive child care center of PGIMER with
facilities to provide all the diagnostic, curative
and rehabilitative services for children. APC
is divided onto A, B, C and D blocks.
In the experiment group (n =106),
infants were breast-fed before, during, and
after their immunization. The control infants
(n = 110) were positioned in their mother’s
lap during the procedure. Purposive sampling,
based on exclusion and inclusion criteria, was
used to select the study subjects who were
randomly assigned to the experimental
(breast-feeding while injecting vaccine) group
or the control group on a weekly basis.
Infants were considered to be eligible
for the study if they were between 2 and 4
months old and were brought to the hospital
for their routine primary immunization
including, diphtheria and tetanus toxoids and
acellular per tussis vaccine (D.P.T) or
combination vaccines of D.P.T which also
include Hepatitis B and Hib vaccines. Infants
weighing 2.5 kg or more and those whose
Nursing and Midwifery Research Journal, Vol-5, No. 4,October 2009 145
parents were willing for par ticipation of their
infants in the study were included.
Infants excluded from the study were
the infants having a concurrent illness
(including congenital conditions that could
alter the response to pain), preterm infants,
infants not on breast-feeding and those for
whom an informed verbal parental consent
could not be obtained. Infants already taken
during the previous visit were also excluded
from the study in the present visit.
The research tools included
1) Protocol for feeding the infant on breast,
2) Protocol for injecting the vaccine, 3) Pain
assessment scale (Modified Behavioral Pain
Scale, MBPS) and 4) Performa for sample
selection and identification data sheet. The
infants behavior before and af ter the
injection was observed by the researcher
and scored on the MBPS. Crying from onset
after the first injection (incase more than one
injection was to be administered) to
cessation, up to a maximum of 3 minutes,
was recorded with an electronic stop watch
by the researcher.
The experiment was carried out in three
phases. Pre-vaccination phase included the
positioning of the infant in the mothers lap.
The infant belonging to the control arm was
positioned in the mother’s lap. For the infant
belonging to the intervention arm, the infant
was positioned in the mother’s lap and was
put on breast feeding. Vaccination phase
included injecting the vaccine by the staff nurse
and observation of the infant’s behavior by the
researcher. The researcher observed the infant
for behavioral responses to pain and the
duration of cry. Post-vaccination phase included
the recording of the infant’s behavior on pain
assessment scale and calculating the total pain
score of the infant. It also included the recording
of duration of infant’s cry.
Results
Age of the study subjects ranged from 5
weeks to 24 weeks in the experimental and
control groups. Half of infants in both the
groups i.e 56 (52.8%) in control group and 62
(56.3%) in experimental group were in 6-12
weeks age group. Males were found to be
more in both the groups as compared to the
females as the experimental group (infant put
on breast while injecting vaccine) comprised
of 69 (62.7%) males and control group (infants
not put on breast while injecting vaccine) had
58 (54.7%). Most of the infants were of normal
weight i.e. 90% in experimental group and 83%
in control group. Majority of the infants i.e. 105
(95.5%) infants in the experimental group and
96 (90.6%) infants in the control group received
combinant vaccines. Non-parametric Chi
square test shows that both the groups were
homogenous as per age, gender, nutritional
status and type of vaccine received (p>0.05)
(Table 1).
Nursing and Midwifery Research Journal, Vol-5, No. 4,October 2009 146
Table-1 : Distribution of subjects (N=216)
Variable n(%)
Expt Gp (n=110) Control gp (n=106) X2 test
AGE (weeks)
• 0-6 2 (1.8) 8 ( 7.6) 0.32*
• 6-12 62 (56.3) 56 (52.8) df = 2
• 12-18 39 (35.5) 37 (34.9)
• 18-24 07 (6.4) 05 (4.70)
Gender
• Male 69 (62.7) 58 (54.7) 1.429* df=1
• Female 41 (37.3) 48 (45.3)
Nutritional status
• Normal 99 (90.0) 88 (83.0) 1.27*, df=3,
• Grade I malnutrition 10 ( 9.1) 11 (10.4)
• Grade II malnutrition 01 (0.9) 06 ( 5.7)
• Grade III malnutrition 1 (0.9)
Type of vaccine received
• D.P.T 005 (4.5) 10 (9.4) 1.99*, df=1
• Combination vaccines 105 (95.5) 96 (90.6)
of DPT
NS*–Not significant
While administration of vaccine, it was
observed that infants in the experimental
group (infant put on breast while injecting
vaccine) had mean duration of cry of 49.3
seconds whereas the control group (infant
not put on breast while injecting vaccine) had
mean duration of cry of 87.4 seconds. The
results of t- test revealed that the infants in
experimental group had significantly lesser
duration of cry as compared to infants in
control group (p<0.01) (Table 2).
Nursing and Midwifery Research Journal, Vol-5, No. 4,October 2009 147
Table-2 : Comparison of cry duration among subjects (N=216)
Groups n Duration of cry (seconds) t test
Range Mean±S.D
Exp. group 110 7-170 49.4 ± 35.3 6.9* P < 0.01
Control group 106 17-230 87.4 ± 44.2 df = 214
*Significant
The Modified Behavioral Pain Score
(MBPS) was used to score pain perception of
infants and it was found that in experimental
group 60 (54.5%) infants had moderate pain
(i.e. pain score ranged from 4-6) whereas in
control group nearly half of the subjects
(55.7%) had severe pain (pain scores ranged
from 7-10). It was also observed that none
of the infants in control group had mild pain
during injecting vaccine (Table 3).
Table-3 : Distribution of subjects as per the pain scores on modified behavioral pain
scale (MBPS) (N=216)
Pain scores on MBPS Expt. gp (n=110) Control gp (n=106)
Range f(%) Range f(%)
(Scores) (Scores)
Pre-vaccination scores
0-3 0-4 109 (99.1) 0-3 101 (95.3)
4-6 01 (0.9) 06 (4.7)
Post-vaccination scores
0-3 3-10 01 (0.9) 4-10 —
4-6 76 (69.1) 04 (37.7)
7-10 33 (30.0) 102 (62.3)
Net pain scores*
0-3 2-7 39 (35.5) 4-9 0 (0.0)
4-6 60 (54.5) 47 (44.3)
7-10 11 (10.0) 59 (55.7)
*(Net pain scores on MBPS = Post-vaccination MBPS scores – Pre-vaccination MBPS scores)
0-3 Mild pain, 4-6 Moderate pain, 7-10 Severe pain.
Nursing and Midwifery Research Journal, Vol-5, No. 4,October 2009 148
The intra-group comparison in relation
to age, gender, dose of vaccine received and
nutritional status of infants indicated no
statistical significant difference in above
mentioned variables in relation to pain
perception. This means that these variables
of infants have no impact on the perception
of pain intensity while undergoing vaccination
(p>0.05) (Table 4).
Table-3: Comparison of pain scores of subjects (N=216)
MBPS pain score
Exp. Group (n= 110) Control group (n=106)
n Mean ±S.D n Mean ±S.D
Age (weeks)
• 0-6 2 3.5±0.7 8 6.5±1.5
• 6-12 62 4.4±1.3 56 7±1.1
• 12-18 39 4.9±1.6 37 6.8±1.3
• 18-24 7 5.3±2.3 5 6.6± 1.5
ANOVA SS = 11.804, F = 1.793 SS = 2.58, F = 0.578
MSS = 0.862, df = 3, NS* MSS = 3.94, df = 3, NS*
Gender
• Male 69 4.5 ± 1.4 48 6.8 ± 1.2
• Female 41 4.9 ± 1.5 58 6.9 ± 1.1
t-test 1.4, df = 108, NS* 0.44,df = 104, NS*
Dose of vaccine received
• 1st dose (n=57) 45 4.4 ± 1.4 57 7.0 ± 1.1
• 2nd dose (n=22) 29 4.1 ± 1.2 22 6.4 ± 1.0
• 3rd dose (n=27) 36 5.3 ± 1.6 27 6.8 ± 1.4
ANOVA SS=26.6 , MSS=1.3, F=6.5 SS=5.7, MSS= 2.8, F = 2.1
df = 2, NS* df = 2, NS*
Nutritional status
• Normal weight 99 4.6± 1.6 88 6.9 ± 1.2
• Grade I malnutrition 10 4.6± 1.1 11 6.9 ±1.0
• Grade II malnutrition 1 5 6 5.8 ±1.2
• Grade III malnutrition — — 88 6
ANOVA SS=25.6 , MSS= 1.4, F=6.7 SS=6.7, MSS= 2.6, F = 2.2
df = 3, NS* df = 3, NS*
NS* Not Significant
Nursing and Midwifery Research Journal, Vol-5, No. 4,October 2009 149
The inter group comparison of net
mean pain scores of the infants in
experimental and control groups revealed
that the experimental group had mean pain
score of 6.8 and control group had 4.6 mean
pain score. t- test was applied to test the null
hypothesis. Hence the null hypothesis was
rejected and it was proved that breast feeding
during injecting vaccine reduces the
perception of pain among the infants (p<0.01)
(Table 4).
Table 4. Comparison of net pain scores among subjects on MBPS
Groups n Net Pain Scores (MBPS) t test
Range Mean ± S.D
5.5*
Control group 106 4-9 6.8 ± 1.2 df = 214, p< 0.01
Exp. group 110 2-7 4.6 ± 1.5
Discussion
Giving immunizations by injection is
essential in the provision of primary care to
infants, but it is also distressing experience
for them. This was confirmed by the present
study. The increasing awareness about the
infant’s ability to perceive pain similarly as in
adults and the immediate and long term grave
effects of painful stimuli on the physiology
and psychology of the infants has led to an
increased focus on the assessment and
management of acute pain among the infants.
Inspite of the increased focus, vaccine related
pain remains largely untreated thereby
becoming a cause of concern among the
health professionals. It is also of concern as
vaccine has become inseparable part of the
health care services thereby increasing the
number of vaccine injections that the infants
have to receive.
Vaccine related pain is not only a
warning of impending or actual injury, but
also has damaging effects in terms of
metabolic and behavioral responses induced
by it. Subsequent pain perception and
response to painful stimuli is effected in long
term with multiple painful experiences. There
are studies per taining to various pain related
variables like needle gauze, the injection site
and technique etc. and the interventions that
are done to reduce the perception of pain
intensity like oral sucrose administration or
provision of pacifiers to the infants. However,
they have been rendered ineffective as oral
sucrose might lead to development of diarrhea
and the pacifier only mechanically obstructs
the infant from crying. Moreover, the pain
should ideally be managed at the point when
it occurs and not either before of after the pain
has already occurred.
Thus, the present study was under taken
with an objective to assess the effect of feeding
the infant on breast during injecting vaccine
on perception of pain intensity among infants.
Nursing and Midwifery Research Journal, Vol-5, No. 4,October 2009 150
In the present study infants receiving D.P.T
and its combination vaccines were taken up
as study subjects, as the above mentioned
vaccine comprises the bulk share of the
vaccine administered to the infants. This is
the reason that a number of other researchers
have preferred to take infants receiving DPT
vaccines. 19, 39, 55
The infants up to the age of 24 weeks
were included in the study; as this is the age
when DPT vaccine is administered to the
infants. Other researchers have also taken
study subjects up to 24 weeks of age in their
studies on vaccination in infants.55
Increased concern about infant pain
and its management have raised some critical
questions about the accuracy of assessment
of acute and procedural pain in clinical
settings. The quantification of children’s pain
experiences still remains a challenge among
the researchers. A variety of pain assessment
approaches namely behavior observation;
physiological technique and self report by the
patient have been used to accurately quantify
an infant’s pain perception.39 In the present
study the Modified Behavioral Pain Scale
(MBPS) was used to objectively measure the
pain expressed by the infants taking into
account the behavioral response.
The study findings revealed that
injecting vaccine during breast feeding
results in decreased perception of pain by
the infants as compared to vaccine
administration without breast feeding. A
reduction in response to pain among infants
who were breast feeding during the injection
was detected. Breast feeding during the
injection markedly suppressed crying. The
present study used crying as an indicator of
pain. The analysis of audible crying is not only
a crude tool for assessment of distress in
infants but also an objective measurement. It
was found that breast feeding was associated
with significantly reduced total crying time in
infant’s receiving an immunization injection.
Indeed, 8 infants in the experimental group had
duration of cry less than or equal to 10
seconds. The remaining breast-feeding infants’
length of crying was significantly shor ter than
that of control group infants.
Other studies in literature have repor ted
similar results with different methodologies.
For example, skin to skin contact was shown
to be effective in reducing the pain experienced
during a heel lance.55 Bilgen et al (2001)
compared the analgesic effects of sucrose,
expressed breast milk and breast feeding
during heel pricks. Breast feeding was allowed
for 2 minutes and then stopped before a heel
prick. This type of inter vention had no
analgesic effect, possible because breast
feeding was not continued during the
procedure. 56 Recently, Gray et al (2002)
repor ted that breast feeding before, during and
after heel prick markedly reduced crying as
well as grimacing and prevented an increase
in heart rate in term neonates as compared
with swaddled infants in their cots. 50
Uniformly, a period, as much as 3
minutes for some was required for infants to
relax and settle down. In contrast, infants
immediately initiated breast feeding and
Nursing and Midwifery Research Journal, Vol-5, No. 4,October 2009 151
immunization began within seconds after
they had established a good suck. The breast
feeding infants in the current study easily
breast-fed and swallowed the milk during the
immunization injection procedure. None of
the infants was seen to have problems with
aspiration, vomiting, cyanosis or respiratory
distress during the procedure.
A comment on the control group is
necessary. The use of a standard procedure
control group is simultaneously strength and
a limitation of the study. The ability to
compare the analgesic proper ties of breast
feeding with non-breast fed infants reveals
breast feeding’s robust effect. This
behaviorally induced analgesia and similarly
effective procedure of skin to skin contact 54
and orosensory stimulation 50, 51 ,57-60 for
alleviating pain during routine immunization
add to the growing scientific literature and
international consensus of the necessity to
provide appropriate analgesia for the
newborn pain.61
As such, continued use of notreatment
control conditions is becoming
ethically difficult to defend with numerous
safe and effective pain relieving options
available. Finally, the present findings must
be placed in a broader context than relieving
immediate newborn pain or stress. The
rapidly expanding literature about the subtle
stresses experienced by human newborns
convincingly demonstrates that even mild
stress during this early period can cause
permanent changes in the limbic
catecholamine neurotransmission and
exaggerated behavioral and endochronologic
reactivity to mild adult stress.50 The American
Academy of Pediatrics (1998) promoted breast
feeding for proven “health, nutritional,
immunologic, developmental, psychological,
social, economic and environmental benefits.”
62 The present findings now add the benefits
of pain and stress reduction.
Breast feeding, which includes the
components of breast milk, suckling, skin to
skin contact and holding, during immunization
for newborns decreased the intensity of pain
perception by the infants who were breast fed
during injection. Although we should not
underestimate the likely analgesic effects of
breast feeding, we should be careful not to
consider breast feeding to be a suitable
measure for major analgesia or as a substitute
for appropriately planned analgesia in other
procedures. This is simple, inexpensive and
convenient approach, allowing it to be adopted
easily into practice. It is incumbent for all child
health care providers to reduce their patients’
pain whenever possible, especially if pain is
associated with immunization injections.
This study confirms the effectiveness of
breast feeding for the relief of infant crying and
shows that it is of significant use in
immunization clinics. Infant management is a
challenge for health care professionals. Pain
management strategies should be inexpensive,
safe, effective, practical, simple and
convenient. The study provides evidence base
for the recommendations of breast feeding
during injecting vaccines in infants. Breast
feeding is very effective, safe and convenient
to implement and can be super vised by
nurses. The study also paves the way for new
Nursing and Midwifery Research Journal, Vol-5, No. 4,October 2009 152
research in related fields. Only the behavioral
changes were observed in the study. The
infants in the study might relate breast feeding
to a painful experience. The generalization of
this study’s findings is limited by
administration of a single injection. Based on
the findings, the study recommends the use
of breast feeding during injecting vaccine as
an intervention to minimize the vaccine
related pain among the infants.
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