Paediatrica Indonesiana

July 

VOLUME 53

NUMBER 4

Original Article

Breast milk vs. non-nutritive sucking to reduce pain

from minor invasive procedures in neonates
Sevina Marisya, Guslihan Dasa Tjipta, Supriatmo, Emil Azlin

Abstract
Background Neonates undergo many uncomfortable, invasive
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pharmacological interventions may provide valuable alternatives
for pain relief in neonates during minor procedures.
Objective To compare the analgesic effect of orally administered
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underwent minor invasive procedures.
Methods A randomized, open trial was performed at the Haji Adam
0DOLN+RVSLWDOIURP6HSWHPEHUWR'HFHPEHU6XEMHFWVZHUH
healthy, term infants who received injections of either intramuscular
hepatitis B immunization or vitamin K. Subjects were randomly
DOORFDWHGLQWRWZRJURXSVWKRVHZHUHWKHEUHDVWPLONJURXSQ 
DQGWKH116JURXSQ %UHDVWPLONDQG116ZHUHJLYHQWZR
minutes before the injection. The events were recorded by video
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times were recorded. Two observers used the premature infant pain
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Results ,QWKHEUHDVWPLONJURXSWKHUHZDVVLJQLILFDQWUHGXFWLRQLQ
PHDQ3,33VFRUH3 DQGPHDQFU\LQJWLPH3 FRPSDUHG
WRWKH116JURXS7KHUHZHUHQRVLJQLILFDQWGLIIHUHQFHVLQPHDQ3,33
VFRUHDQGFU\LQJWLPHVEHWZHHQPDOHVDQGIHPDOHV3 DQG3 
UHVSHFWLYHO\+RZHYHUWKHUHZDVDVLJQLILFDQWO\ORZHUPHDQ3,33VFRUH
IRUYLWDPLQ.LQMHFWLRQWKDQIRUKHSDWLWLV%LPPXQL]DWLRQ3 
DOWKRXJKPHDQFU\LQJWLPHVZHUHQRWVLJQLILFDQWO\GLIIHUHQW3 
We observed significantly less OGHVDWXUDWLRQDWVHFRQGVSRVW
injection in the breast milk group compared to that of the NNS group.
However, there was no significant difference in heart rate between the
two groups throughout the observation period.
Conclusion Breast milk administered before an invasive minor
procedure effectively reduces pain in neonates. Breast milk
DGPLQLVWHUHGWRQHRQDWHVSULRUWRLQMHFWLRQKDVUHGXFHGPHDQ3,33
scores, crying times, and Odesaturation, compared to neonates
who received NNS in the form of pacifiers. [Paediatr Indones.
2013;53:204-8.].
Keywords: breast milk, non-nutritive sucking, pain,
invasive minor procedure, neonates

204Paediatr Indones, Vol. 53, No. 4, July 2013

ain is defined by the International Association

for the Study of Pain ,$63DV DQ XQSOHDVDQW
VHQVRU\ DQG HPRWLRQDO H[SHULHQFH DVVRFLDWHG
with actual or potential tissue damage or described
in terms of such damage. The definition also states
that pain is always subjective and learned through
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Routine medical care of neonates includes
blood sampling during the first day of life, as well as
injection of vitamin K or vaccines. These procedures
are performed in both healthy and ill neonates. The
ability of neonates to perceive and react to pain has
been acknowledged.3
1HRQDWHVDUHLQFDSDEOHRIYHUEDOVHOIUHSRUWLQJ
but they provide behavioral and physiological cues
to indicate the presence of pain.4 Treating pain in
neonates is essential, both for ethical reasons and
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hemodynamic instability, and increased intracranial
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EH SKDUPDFRORJLF RU QRQSKDUPDFRORJLF 3 1RQ
pharmacologic pain management includes swaddling,
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From the Department of Child Health, University of North Sumatera

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Reprint requests to: Sevina Marisya, Department of Child Health,
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%XQJD/DX1R0HGDQ7HO
)D[(PDLOVHYLQDPDULV\D#JPDLOFRP

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consuming sucrose solutions or breastmilk.
Evaluation of pain in neonates is difficult and
relies on infant reactions, such as changes in behavior,
modifications in physiological variables, or release of
stress hormones to infer pain. Assessments that rely on
various behavioral changes appear to be more accurate
for pain evaluation in neonates.3 A commonly used
test is the Premature Infant Pain Profile3,33VFDOH
7KH 3,33 VFDOH LV D YDOLGDWHG LQGLFDWRU VFDOH IRU
assessment of acute pain in preterm and term infants.
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VWDWHKHDUWUDWHR[\JHQVDWXUDWLRQDQGWKUHHIDFLDO
DFWLRQV EURZ EXOJH H\H VTXHH]H DQG QDVRODELDO
furrow) to yield a pain score. The score ranges from
QRSDLQWRPD[LPXPSDLQ
We aimed to compare the analgesic effect between
orally administered breast milk vs. NNS in neonates
who underwent minor invasive procedures.

by the clinician in charge of the neonates. Two minutes

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milk or a pacifier. Primary measurements included
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FU\LQJWLPHV,QIDQWVZHUHUHFRUGHGRQYLGHRWDSH
The comparison of breast milk vs. NNS
for reducing pain in neonates was analyzed by Chi
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XVLQJ LQGHSHQGHQW 7WHVW 'DWD ZDV FRQVLGHUHG WR
EH VWDWLVWLFDOO\ VLJQLILFDQW IRU 3   DQG 
FRQILGHQFH LQWHUYDOV ,QWHUREVHUYHU FRPSDWLELOLW\
IRU 3,33 VFDOH HYDOXDWHUV ZDV DQDO\]HG E\ .DSSD
coefficient test for interrater agreement, with
VLJQLILFDQFH DFFHSWHG WR EH EHWZHHQ  WR  7KH
correlation between two observers was also analyzed
with Pearsons correlation test. Data was processed
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Results

We conducted a randomized, controlled, open trial

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IURP 6HSWHPEHU WR 'HFHPEHU  $OO QHRQDWHV
admitted to the special care nursery were recruited
by consecutive sampling.
Neonates with normal gestational age, no
contraindication to taking substances orally, and appe
arance, pulse, grimace, activity, respiration (APGAR)
VFRUHVJUHDWHUWKDQDWWKHst and 5th minutes after
ELUWKZHUHHOLJLEOHIRUWKHVWXG\:HH[FOXGHGQHRQDWHV
from high risk pregnancies, who were delivered from
mothers under general anesthesia, from mothers with
drug abuse problems, as well as those with congenital
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from subjects parents or guardians. This study was
approved by the Ethics Committee for Research at
the University of North Sumatera.
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QHRQDWHVIRUHDFKJURXS:HFROOHFWHGWKHIROORZLQJ
GHPRJUDSKLF GDWD IURP VXEMHFWV DJH VH[ W\SH RI
injection, delivery mode, body weight, and APGAR
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the breast milk group or the NNS group, using a
random number table. They received injections, either
intramuscular hepatitis B immunization or vitamin K,

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criteria. No subjects dropped out of the study. Each
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groups had similar baseline characteristics, including
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and APGAR scores (Table 1).
There was good agreement between the two
REVHUYHUVIRU3,33VFDOHHYDOXDWLRQVDVPHDVXUHGE\
.DSSDFRHIILFLHQWZLWK. Figure 1).

30

20

10

PIPPII

Methods

-10
-10

10

20

PIPP I

Figure 1. PIPP scale measurements between the two

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Paediatr Indones, Vol. 53, No. 4, July 2013205

Sevina Marisya et al: %UHDVWPLONYVQRQQXWULWLYHVXFNLQJWRUHGXFHSDLQLQQHRQDWHV

3HDUVRQVFRUUHODWLRQWHVWUHYHDOHGWKDWU 
3 LQGLFDWLQJDVWURQJLQWHUREVHUYHUFRUUHODWLRQ
(Table 2).
We observed no significant differences in mean
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IHPDOHV 3    +HSDWLWLV % LQMHFWLRQV FDXVHG

KLJKHUSDLQOHYHOLQWHUPVRIKLJKHUPHDQ3,33VFRUH
than that of vitamin K injections, however, mean
crying times did not significantly differ. Furthermore,
neonates who received breast milk had significantly
ORZHUPHDQ3,33VFRUHDQGPHDQFU\LQJWLPHWKDQ
that of the NNS group (Table 3).

Table 1. Baseline characteristics of subjects

Breastmilk group
(n=48)

Characteristics
Gender, n (%)
Male
Female
Injection type, n (%)
8KVCOKPHepatitis B
Delivery mode, n (%)
Vaginal
Caesarean
Mean gestational age (SD), weeks
Mean age (SD), days
Mean birth weight (SD), grams
Mean weight (SD), grams
Mean APGAR score at 1st minute (SD)
Mean APGAR score at 5th minute (SD)

NNS group
(n=48)

18 (37.5)
30 (62.5)

25 (52.1)
23 (47.9)

20 (41.7)
28 (58.3)

15 (31.2)
33 (68.8)

24 (50)
24 (50)
36.3 (3.7)
1.9 (1.2)
3,134.6 (356.3)
3,115.6 (361.2)
8 (0.9)
9.8 (1.6)

27 (56.3)
21 (43.7)
36.9 (4.1)
1.7 (1.0)
3,165.4 (467.8)
3,133.8 (469.9)
8.4 (0.8)
10 (1.5)

Table 2. Compatibility in PIPP scale measurements between the two observers by Pearsons correlation test
PIPP II **
Mild pain
PIPP I *

Mild Pain
Moderate Pain
Severe Pain

Total

Moderate pain

Severe pain

Total

15

15

42

42

39

39

15

42

39

96

2+22+2+22UEQTKPID[VJGTUVQDUGTXGT
** PIPP II : PIPP scoring by the second observer

Table 3. PIPP scores and crying times according to breast milk vs. NNS, gender, and
injection type
Groups
Breast milk (n=48)
NNS (n=48)
P value
95% CI of differences
Male (n=43)
Female (n=53)
P value
95% CI of differences
8KVCOKP-
P
Hepatitis B (n=61)
P value
95% CI of differences

206Paediatr Indones, Vol. 53, No. 4, July 2013

PIPP Score (SD)

9.3 (3.6)
12.5 (3.3)
0.001
14.6 to -1.8
11.3 (3.8)
10.6 (3.9)
0.4
0.4 to -0.9
9.3 (3.9)
11.8 (3.5)
0.002
19.3 to -0.4

Crying time (SD), min

19.1 (17.1)
29.4 (28.1)
0.03
19.7 to -0.9
22.3 (23.6)
25.9 (23.7)
0.5
4.1 to 0.9
18.3 (17.7)
27.7 (26.0)
0.06
18.3 to 0.6

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We observed no significant differences in

mean heart rates between the breast milk and NNS
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(Figure 2). However, there was significantly higher
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WKH116JURXSREVHUYHGDWVHFRQGV3 
(Figure 3).

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005

d

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Figure 2. Mean heart rates of the two groups before

and after injection

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d

Figure 3. Mean oxygen saturation of the two groups

before and after injection

Discussion
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times, consistent with a previous study of similar
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features than males.
A significant change in a physiological parameter
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SRVWLQMHFWLRQLQWKH116JURXS+RZHYHUWKHODFN

of a significant difference in heart rate between the

breast milk and NNS groups may have been due to
the insensitivity of the instrument used to measure
heart rate. However, a study in Turkey revealed no
significant differences in the breast milk group which
was administered during the vaccination process, but
this result was due to instrument insensitivity. An
,QGLDQVWXG\FRPSDUHGQHRQDWHVZKRUHFHLYHGHLWKHU
H[SUHVVHGEUHDVWPLONRUDGLVWLOOHGZDWHUSODFHERLQ
terms of their reactions to pain. The breast milk group
had significantly lower heart rate, O desaturation
and crying time than the placebo group. As such,
giving neonates breast milk before they undergo minor
invasive procedures may be a simple and effective
method for pain reduction.
A previous study reported no significant
difference in crying time between groups who received
either colostrum or NNS.,QFRQWUDVWZHIRXQGWKDW
neonates who received breast milk had significantly
decreased crying time than neonates in the NNS
group. Previous studies also concluded that breast
milk was effective for reducing pain in neonates
undergoing minor invasive procedures, as shown
by a spontaneous decreased crying time and heart
rate. This procedure can be recommended for
reducing pain in neonates undergoing minor invasive
procedures.
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scale according to the International Pain Consensus, and
HTXDOWRRWKHUVFDOHVVXFKDVWKHNeonatal Facial Coding
System (NFCS), the Neonatal Infant Pain Scale1,36
the Pain Assessment in Neonates3$,1WKHInfant Body
Coding System,%&6DQGRWKHUSDLQDVVHVVPHQWVFDOHV
in neonates.
A limitation of our study was that observers were
not blinded to subjects groups when they evaluated
the video recordings. Nevertheless, high agreement
among observers during their initial evaluations
indicated objectivity. A second limitation was the
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UDWH +RZHYHU WKH 3,33 VFDOH VKRZHG D VLJQLILFDQW
difference between the two groups, so this limitation
did not lead to bias.
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an invasive minor procedure effectively reduces pain
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WLPHDVZHOODVKLJKHUR[\JHQVDWXUDWLRQFRPSDUHG
WRQRQQXWULWLYHVXFNLQJ

Paediatr Indones, Vol. 53, No. 4, July 2013207

Sevina Marisya et al: %UHDVWPLONYVQRQQXWULWLYHVXFNLQJWRUHGXFHSDLQLQQHRQDWHV

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'HRUDUL $. $QDOJHVLF HIIHFW RI H[SUHVVHG EUHDVW PLON LQ
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FRQWUROOHGGRXEOHEOLQGWULDO$FWD3DHGLDWU

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EUHDVWIHHGLQJRUSDFLILHUXVHZLWKPDWHUQDOKROGLQJLQWHUP
LQIDQWV$PEXO3HGLDWU
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