INTRODUCTION:

Pain is an unpleasant sensory and emotional experience associated with actual or potential damage or described in terms of such damage (International Association for the study of pain, 1979). Routine vaccination is an inherent part of the health care delivery system as it is an effective health intervention in reducing the infant morbidity and infant mortality¹. During childhood, immunization injections are the most common sources of iatrogenic pain².

Intramuscular immunization is administered repeatedly throughout infancy, childhood and adolescence. Pain from vaccine injections is a sources of anxiety and distress for vaccinators, children and their parents and if not addressed, can lead to pre-procedural anxiety at future medical fears, and health care avoidance behaviors including non-adherence with immunization schedules³. It is estimated that up to 25% of adults have needle fears⁴. Needle fears among most of the people develop during childhood⁵. Efforts are made to minimize pain in childhood have the potential to prevent the development of needle fears and promote consumer satisfaction and trust in the health care delivery system because of more positive experiences for children their families³. Most of the injectable vaccines are administered in the first year of the child-life which produces pain and distress among children^6,7. Pain management in infants is difficult as they cannot verbally express pain and it is really a neglected domain.

For managing pain both pharmacological and non pharmacological methods can be used. Out of various non pharmacological methods breast feeding for managing pain is the preferred method during infancy. A study conducted on breast feeding in which 478 infants (<12 months) were compared breastfeeding before, during and after vaccine injections to either no intervention [i.e. mother seated with infant in her arms (Dilli 2008¹⁰) or swaddling infants in bassinets (Efe 2007¹¹) or routine care (not described, Moddares 2006¹²) or restraint of infants by mothers (Razek 2009¹³).

OBJECTIVE:

To find out the effect of breastfeeding on pain response in infants during immunizing intramuscular injection

Methods:

A quasi-experimental study was conducted with infants who were brought to the vaccination room of pediatric O.P.D of IMS and SUM Hospital, Bhubaneswar, between December 2013 to February 2014. It is a tertiary care center which provides super specialty diagnostic, curative and therapeutic health care services to the people. The study was approved by institution ethical committee. Written consent was sought from the parents of infants, whose parents wiling for participation in the study. Subjects were selected by using purposive sampling based on the exclusive and inclusive criteria. Infants were considered to be eligible for the study if they were within 1 year of age and brought to the immunization clinic for their routine immunization including diphtheria, pertussis and tetanus toxoids etc. Infants excluded from the study were the infants having a concurrent illness (including congenital condition), ulcers or patches present in mouth. Infants already taken during the previous visit were also excluded. The infants were selected as sample and assembled in a room. The sample was randomly divided into two groups: experimental group and control group by lottery methods. The procedure and purpose of data collection were explained in detail to the parents of the infants. The mothers of the infants of experimental group were advised to administer breastfeeding 60seconds prior to intramuscular injection administration. Proper breastfeeding technique was also assessed in those mothers. But the mothers of the infants of control group were not advised to breastfed their infants before intramuscular injection administration. The research tools included:-

a. Interview schedule to collect the demographic data

b. Guide line for feeding the infant on breast

c. Protocol for injecting the vaccine

d. Pain assessment scale (Neonatal infant pain scale)

Soon after the administration of intramuscular injection the intensity of pain was assessed by observing the parameters such as facial expression, cry, breathing patterns, arms, legs and state of arousal upto a maximum of 3 minutes was recorded with a stop watch by the researcher and average score was taken.

The experiment was carried as follows:

In pre vaccination phase, position of infants arm in the mother’s lap and was put on breast as per the breast feeding guideline. Infants belonging to the control group, arm was the positioned in the mother’s lap. During vaccination phase it included injecting the vaccine by the staff and observation of infant’s behavior by the researcher in post vaccination phase included the recording of the infant’s behaviour on NIPS. Then the intensity of pain for both the groups were assessed by the behavioral assessment for measurement of pain through the Neonatal Infant Pain Scale.

RESULT:

Sociodemographic profile of the subject:

Age of the study sample ranges from 6weeks to 14 weeks in the experimental and 6 weeks to 11 weeks in the control groups. Infants in both group i.e. 27(45%) experimental group and 30(50%) in the control group in the age 10-11 weeks and 6 to 7 weeks of age respectively. Female children were more in the control group than the male children. More than half of the infants were of normal weight i.e. 51.66% in experimental group and 63.33% in control group. Most of the infants were in term during delivery i.e. 65% in experimental group and 91.66% in control group. Maximum infants had birth order one, in both the group. Most of the infants were in between 20-30cm. related to mid thigh circumference of both the group.

Experimental Group depicted that in 71.66% infants the facial expression was relaxed and in 28.33% infants, it was grimace. 46.66% infants did not cry at all, 48.33% infants whimpered and 5% infants had vigorous crying. In 78.33% infants, the breathing pattern was relaxed and in 21.66% there was change in breathing. 48.33% infants had their arms in restrained or relaxed manner and 51.66% infants had their arms in flexed or extended manner. 58.33% infants had their legs in restrained or relaxed manner and 41.66% infants had their legs in flexed or extended manner. 81.66% infants were sleeping and 18.33% infants were awake.

Control Group depicted that in 3.33% infants, the facial expression was relaxed and in 96.66% infants it was grimace. Every infant cried among which 21.66% infants whimpered and 38.33% infants had vigorous crying. In 13.33% infants, the breathing pattern is relaxed and in 86.66%, there is change in breathing. 5% infants had their arms in restrained or relaxed manner and 95% infants had their arms in flexed or extended manner. 3.33% infants had their legs in restrained or relaxed manner and 96.66% infants had their legs in flexed or extended manner. 10% infants were sleeping, 56.66% infants were awake and 33.33% infants were fussy.

Table -1 Distribution of subjects n=120

VARIABLES		Experimental Group n =60 f(%)	Control Group n=60 f (%)
AGE	6-7WKS	25(41.66)	30(50)
	8-9WKS	7,(11.66)	2(3.33)
	10-11WKS	27(45)	28(46.66)
	>12WKS	1(1.66)	0(0)
SEX OF BABY	MALE	30(50)	22(36.66)
SEX OF BABY	FEMALE	30(50)	38(63.33)
WT OF BABY	<2.5KG	3(5)	0(0)
	2.5-5KG	31(51.66)	39(65)
	5.1-7.5 KG	21(35)	12(20)
	7.6-10 KG	5(8.33)	9(15)
	>10 KG	0(0)	0(0)
COND OF THE BABY DURING DELIVERY	LBW	7(11.66)	0(0)
	PRE TERM	14(23.33)	5(8.33)
	TERM	39(65)	55(91.66)
BIRTH ORDER	1	26(43.33)	46(76.33)
	2	15(25)	11(18.33)
	3	9(15)	2(3.33)
	4	0(0)	1(1.66)
MTC	<20CM	5(8.33)	4(6.66)
	20-30CM	46(76.66)	35(58.33)
	30-40CM	9(15)	21(35)

Table 2 Distribution of subjects as per nips scores n=120

Parameters		Experimental Group n=60 Frequency, %	Control Group n=60 Frequency , %
Facial Expression	Relaxed	43 (71.66)	2 (3.33)
Facial Expression	Grimace	17 (28.33)	58 (96.66)
Cry	No cry	28 (46.66)	0 (0)
	Whimper	29 (48.33	13 (21.66)
	Vigorous crying	3 (5)	47 (38.33)
B pattern	Relaxed	47 (78.33)	8 (13.33)
B pattern	Change in breathing	13 (21.66)	52 (86.66)
Arms	Restrained or Relaxed	29 (48.33)	3 (5)
Arms	Flexed or Extended	31 (51.66)	57 (95)
Legs	Restrained or Relaxed	35 (58.33)	2 (3.33)
Legs	Flexed or Extended	25 (41.66)	58 (96.66)
State of arousal	Sleeping	49 (81.66)	6 (10)
	Awake	11 (18.33)	34 (56.66)
	Fussy	0 (0)	20 (33.33)

Table 3: Association of socio-demographic variables in experimental and control group

Variables	Experimental group	Control group	Chi	Df	P value
AGE (WEEK)
<9Wks	32	32	0.03	1	0.8625
>9wks	28	28
GENDER
MALE	30	22	1.66	1	0.1976
FEMALE	30	38
WT.OF THE BABY
2.5-5kg	34	39	3.94	2	0.1395
5.1-7.5kg	21	12
7.6-10Kg	5	9

Table 4.Comparison of pain scores of subject

	Experimental group			Control group			Mean% Differences	Unpaired T test	Df	P value
AREAS	MEAN	MEAN%	SD	MEAN	MEAN%	SD
F EXP	0.28	28.33	0.45	0.96	96.66	0.18	68.33	10.82	118	<0.0001
CRY	0.58	58.33	0.59	1.78	178	0.42	119.67	12.87	118	<0.0001
B PATTERN	0.23	23.33	0.46	0.88	88.33	0.32	65	0	118	1
ARMS	0.51	51.66	0.57	0.95	95	0.22	43.34	6.11	118	<0.0001
LEGS	0.41	41.66	0.497	0.96	96.66	0.18	55	8.05	118	<0.0001
S O A	0.18	18.33	0.39	0.81	81.66	0.39	63.33	8.89	118	<0.0001

Table – 5 Subject Distribution according to level of pain n: 120

Pain Score	Exp. Group	Cntrl. Group	CHI	DF	P Value
NO PAIN/MILD PAIN (0-2)	33(55)	0	0	-1	1
MODERATE PAIN (3-4)	21(35)	6(10)	infinity	1	<0.001
SEVERE PAIN ( >4)	5(8.33)	54(90)	infinity	1	<0.0001

No significant association was found between the experimental group and control group in respect to the selected demographic variables like age, gender, weight of the baby in relation to pain perception. Comparison of pain scores of the infants after I.M vaccination in experimental and control group were 0.28, 0.58, 0.23, 0.51, 0.41, 0.18, 0.96, 1.78, 0.88, 0.95, 0.96 and 0.81 respectively unpaired t-test was applied to test the Null hypothesis, Hence null hypothesis was rejected and it was proved that breast feeding during injecting vaccine reduces the perception of pain among the infants (at P<0.0001).

It- highlights the distribution of subjects as per NIPS among experimental group and control group. In experimental group 33(55%) of infants had no pain where as in control group every infant felt pain. 21(35 %) and 6(10%) (x²= infinity df = P<0.001) had moderate pain in experimental group and control group. Only 5 (8.33 %) had severe pain in experimental group but 54 (90%) had severe pain in control group infants (x² – infinity) (df = 1, P<0.0001).

DISCUSSION:

Immunizations are administered repeatedly during infancy to reduce the vaccine preventable diseases. But it creates anxiety and distress among the children which can lead to pre-procedural anxiety and future medical fears and health care avoidance behaviors. Thus the present study was undertaken with an objective to assess the effect of breast feeding on pain response in infants during immunizing intramuscular injection. In the present study infants receiving D.P.T vaccines were taken up as a study subject. The infants upto the age of one year were included in the study. Neonatal infant pain scale (NIPS) was used to objectively measure the pain intensity during injecting intra muscular vaccine. The findings of the present study revealed that injecting intra muscular vaccine during breast feeding result in decrease perception of pain by the infants as compared to injecting vaccine without breast feeding. Breast feeding during injecting vaccine markedly suppressed crying, breathing pattern in relaxed condition arms legs also in relaxed condition. 28(46.66%) infants in the experimental group had no crying, 47(78.33%) continue the breasting pattern in relaxed condition , arms and legs of infants 29(48.33%) and 35(58.33%) were in relaxed position and 49(81.66%) were at the (sleeping) state of arousal. The above parameters in case of control group as follows vigorous crying 47(38.33%), 52(86.66%) changes in their breathing pattern , 57(95%) arms were extended, 58 (96.66%) legs were extended and 20 (33.33%) were in fussy. Other studies in literature have reported similar results with different methodologies. Mitra Savabi Esfahani et. al. (2013) breast feeding during injecting vaccine reduces pain more than message therapy¹⁴. Lovepreet Kaur et. al. (2009) Quasi experimental RCT, 216 infants (<= 24weeks) during breast feeding injecting vaccine as an intervention to minimize the vaccine related pain¹⁵. Breast feeding which includes different components such as sweet testing solution, sucking, holding and skin to skin contact decrease the intensity of pain perception who were breast fed during injection. It is simple, inexpensive, convenient, having no side effect and allowing it to be adopted easily into practice. This study found that breastfed infants had less pain during injecting intra muscular injection. Offering breast milk or formula via a bottle is not equivalent to breast feeding and should not be considered as a substitute for breast feeding.

RECOMMENDATION:

The study also provides the way for new research in the related fields. Only some of the parameters were observed in the study. The generalization of this study can be done by taking large number of samples. Based on the findings, the study recommends the use of breast feeding during injecting intramuscular vaccines is an intervention to minimize the pain among the infants.

CONCLUSION:

It was concluded that the perception of pain intensity is less among the infants when vaccine injection is administered during breast feeding. It needs less time, minimum efforts and cost effective without side effect which can be used easily in clinical settings.

REFERENCE:

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Received on 03.06.2015 Modified on 26.06.2015

Asian J. Nur. Edu. and Research 6(1): Jan.- Mar.2016; Page 27-31

DOI: 10.5958/2349-2996.2016.00006.9