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Meta-Analysis
. 2012 Dec 12;12(12):CD004950.
doi: 10.1002/14651858.CD004950.pub3.

Breastfeeding or breast milk for procedural pain in neonates

Prakeshkumar S Shah  1 , Cecilia Herbozo, Lucia Liz Aliwalas, Vibhuti S Shah
Affiliations
Meta-Analysis

Breastfeeding or breast milk for procedural pain in neonates

Prakeshkumar S Shah et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Physiological changes brought about by pain may contribute to the development of morbidity in neonates. Clinical studies have shown reduction in changes in physiological parameters and pain score measurements following pre-emptive analgesic administration in situations where the neonate is experiencing pain or stress. Non-pharmacological measures (such as holding, swaddling and breastfeeding) and pharmacological measures (such as acetaminophen, sucrose and opioids) have been used for this purpose.

Objectives: The primary objective was to evaluate the effectiveness of breastfeeding or supplemental breast milk in reducing procedural pain in neonates. The secondary objective was to conduct subgroup analyses based on the type of control intervention, gestational age and the amount of supplemental breast milk given.

Search methods: We performed a literature search using the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 10), MEDLINE (1966 to February 2011), EMBASE (1980 to February 2011), CINAHL (1982 to February 2011), abstracts from the annual meetings of the Society for Pediatric Research (1994 to 2011), and major paediatric pain conference proceedings. We did not apply any language restrictions.

Selection criteria: Randomised controlled trials (RCTs) or quasi-RCTs of breastfeeding or supplemental breast milk versus no treatment/other measures in neonates were eligible for inclusion in this review. The study must have reported on either physiologic markers of pain or validated pain scores.

Data collection and analysis: We assessed the methodological quality of the trials using the information provided in the studies and by personal communication with the authors. We extracted data on relevant outcomes, estimated the effect size and reported this as a risk ratio (RR), risk difference (RD) and weighted mean difference (MD) as appropriate.

Main results: Of twenty eligible studies, ten evaluated breastfeeding and ten evaluated supplemental breast milk. Sixteen studies analysed used heel lance and four used venepuncture as procedure. We noted marked heterogeneity in control intervention and pain assessment measures among the studies. Neonates in the breastfeeding group had statistically a significantly lower increase in heart rate, reduced proportion of crying time and reduced duration of first cry and total crying time compared to positioning (swaddled and placed in a crib), holding by mother, placebo, pacifier use, no intervention or oral sucrose group, or both.Premature Infant Pain Profile (PIPP) scores were significantly lower in the breastfeeding group compared to positioning, placebo or oral sucrose group, or both. However, there was no statistically significant difference in PIPP scores when compared to no intervention. Douleur Aigue Nouveau-ne scores (DAN) were significantly lower in the breastfeeding group compared to the placebo group and the group held in mother's arms, but not when compared to the glucose group. Neonatal Infant Pain Scale (NIPS) was significantly lower in the breastfeeding group compared to the no intervention group, but there was no difference when compared to the oral sucrose group. The Neonatal Facial Coding System (NFCS) was significantly lower in the breastfeeding group when compared to oral glucose, pacifier use, holding by mother and no intervention, but no difference was found when compared to formula feeding.Supplemental breast milk yielded variable results. Neonates in the supplemental breast milk group had a significantly lower increase in heart rate, a reduction in duration of crying and a lower NFCS compared to the placebo group. Neonates in the supplemental breast milk group had a significantly higher increase in heart rate changes when compared to the sucrose group. Sucrose (in any concentration, i.e. 12.5%, 20%, 25%) was found to reduce the duration of cry when compared to breast milk, as did glycine, pacifier use, rocking, or no intervention. Breast milk was found not to be effective in reducing validated and non-validated pain scores such as NIPS, NFCS, and DAN; only being significantly better when compared to placebo (water) or massage. We did not identify any study that has evaluated safety/effectiveness of repeated administration of breastfeeding or supplemental breast milk for pain relief.

Authors' conclusions: If available, breastfeeding or breast milk should be used to alleviate procedural pain in neonates undergoing a single painful procedure rather than placebo, positioning or no intervention. Administration of glucose/sucrose had similar effectiveness as breastfeeding for reducing pain. The effectiveness of breast milk for painful procedure should be studied in the preterm population, as there are currently a limited number of studies in the literature that have assessed it's effectiveness in this population.

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Conflict of interest statement

None.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Forest plot of comparison: 1 Breastfeeding vs control, outcome: 1.9 Neonatal Facial Coding Score (NFCS).
5
5
Forest plot of comparison: 2 Supplemental breast milk vs control, outcome: 2.8 Neonatal Facial Coding Score (NFCS) at 2 minutes.
6
6
Forest plot of comparison: 2 Supplemental breast milk vs control, outcome: 2.9 Douleur Aigue du Nouveau‐né (DAN) at 2 minutes.
1.1
1.1. Analysis
Comparison 1 Breastfeeding vs control, Outcome 1 Heart rate change (beats per minute).
1.2
1.2. Analysis
Comparison 1 Breastfeeding vs control, Outcome 2 Oxygen saturation change.
1.3
1.3. Analysis
Comparison 1 Breastfeeding vs control, Outcome 3 Blood pressure changes (mm of Hg).
1.4
1.4. Analysis
Comparison 1 Breastfeeding vs control, Outcome 4 Percentage of time crying.
1.5
1.5. Analysis
Comparison 1 Breastfeeding vs control, Outcome 5 Duration of crying (seconds).
1.6
1.6. Analysis
Comparison 1 Breastfeeding vs control, Outcome 6 Duration of first cry (seconds).
1.7
1.7. Analysis
Comparison 1 Breastfeeding vs control, Outcome 7 Neonatal Infant Pain Scale (NIPS).
1.8
1.8. Analysis
Comparison 1 Breastfeeding vs control, Outcome 8 Premature Infant Pain Profile Score.
1.9
1.9. Analysis
Comparison 1 Breastfeeding vs control, Outcome 9 Neonatal Facial Coding System (NFCS).
1.10
1.10. Analysis
Comparison 1 Breastfeeding vs control, Outcome 10 Douleur Aigue Nouveau‐né (DAN) Scale.
1.11
1.11. Analysis
Comparison 1 Breastfeeding vs control, Outcome 11 Composite score.
2.1
2.1. Analysis
Comparison 2 Supplemental breast milk vs control, Outcome 1 Heart rate change (beats per minute).
2.2
2.2. Analysis
Comparison 2 Supplemental breast milk vs control, Outcome 2 Oxygen saturation change.
2.3
2.3. Analysis
Comparison 2 Supplemental breast milk vs control, Outcome 3 Percentage of time crying.
2.4
2.4. Analysis
Comparison 2 Supplemental breast milk vs control, Outcome 4 Duration of crying (seconds).
2.5
2.5. Analysis
Comparison 2 Supplemental breast milk vs control, Outcome 5 Duration of first cry (seconds).
2.6
2.6. Analysis
Comparison 2 Supplemental breast milk vs control, Outcome 6 Neonatal Infant pain scale (NIPS).
2.7
2.7. Analysis
Comparison 2 Supplemental breast milk vs control, Outcome 7 Neonatal Facial Coding Score at 3 minutes.
2.8
2.8. Analysis
Comparison 2 Supplemental breast milk vs control, Outcome 8 Neonatal Facial Coding Score (NFCS) at 2 minutes.
2.9
2.9. Analysis
Comparison 2 Supplemental breast milk vs control, Outcome 9 Douleur Aigue du Nouveau‐né (DAN) at 2 minutes.
2.10
2.10. Analysis
Comparison 2 Supplemental breast milk vs control, Outcome 10 Body pain score.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Okan 2010 {published data only}
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References to studies excluded from this review

Bilgen 2001 {published data only}
    1. Bilgen H, Ozek E, Cebeci D, Ors R. Comparison of sucrose, expressed breast milk, and breast‐feeding on the neonatal response to heel prick. Journal of Pain 2001;2:301‐5. - PubMed
Efe 2007a {published data only}
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Iturriaga 2009 {published data only}
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Osinaike 2007 {published data only}
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References to ongoing studies

NCT00175409 {unpublished data only}
    1. NCT00175409. Breast feeding analgesia in preterm infants. www.clinicaltrials.gov/ct2/show/NCT00175409?term=breastfeeding&cond=... (accessed 11 April 2011).
NCT00414258 {unpublished data only}
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NCT00908401 {unpublished data only}
    1. NCT00908401. Analgesic effect of breastmilk for procedural pain in preterm infants (BMoS). www.clinicaltrials.gov/ct2/show/NCT00908401?term=breast+milk&cond=pa... (accessed 22 May 2009).
NCT01276366 {unpublished data only}
    1. NCT01276366. Amphia premature infant pain study (APIP). www.clinicaltrials.gov/ct2/show/NCT01276366?term=breast+milk&cond=pa... (accessed 23 April 2010).
NCT01355640 {unpublished data only}
    1. NCT01355640. Two methods of analgesia for Chinese term infants receiving heel lance. www.clinicaltrials.gov/ct2/show/NCT01355640?term=breastfeeding&cond=... (accessed 1 June 2011).

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References to other published versions of this review

Shah 2006
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