Physical interventions better than sucrose at relieving pain from infant immunizations

Oral sucrose reduces pain from infant immunizations, but the 5 S’s (swaddling, side/stomach position, shushing, swinging, and sucking) is more effective, according to a study published in the journal Pediatrics.

Key Point: Pain scores and other signs of discomfort in infants receiving immunizations were lower in those treated with the 5 S’s—swaddling, side or stomach position, shushing, swinging, and sucking—than in infants treated with sucrose only or those in a control group. The 5 S’s can be implemented even in low-resource settings with minimal training.

Pediatricians are, of course, interested in reducing both the infants’ pain and the parental anxiety about any immunization-related pain, in part because of the effect the parental anxiety level can have on the baby—so this study examined both.

Researchers at Eastern Virginia Medical School in Norfolk, Virginia, United States, conducted a randomized controlled trial of 230 infants given 3 injected immunizations at 2 months and 4 months. The infants were divided into 4 groups: control (56 infants; water before immunization and parent/caregiver comfort after); sucrose (58 infants; oral sucrose before and parent/caregiver comfort after); physical (58 infants; water before and 5 S’s by medical resident researchers after); and sucrose and physical (58 infants; sucrose before and 5 S’s by medical resident researchers after).

Using pain scores and crying as a measure of discomfort/pain, the researchers determined that the [s2If !is_user_logged_in()]…
[/s2If][s2If is_user_logged_in()] physical group (5 S’s only) provided the same pain relief as the sucrose and physical group, and better pain relief than the sucrose-only group. The infants in this study were administered oral Rotarix first, followed by the hepatitis B vaccine, Pentacel, and Prevnar in alternating thighs.

The 5 S’s are described by Harvey Karp, MD, FAAP, in his book The Happiest Baby on the Block. Pediatric residents watched the 5 S’s video and learned how to swaddle the babies within 15 seconds of the last vaccination, followed by placing the baby in the side or stomach position, shushing, swinging, and giving a pacifier within 30 seconds. (To see a video of the 5 S’s, go to

In India, interventions that can improve routine immunization are encouraged, according to a review published in Indian Pediatrics in 2009 ( Reducing pain for the infants is an important intervention worldwide, but it’s important to note that certain medical interventions that are evidence-based in other countries may not be practical for widespread adoption in India. For example, local anesthetics that take time to work and are expensive and technically demanding “are unsuitable for routine immunization in India,” according to the 2009 article. The 5 S’s have the advantage of being practical and cost-effective to administer even in low-resource settings.

Source: Harrington JW, Logan S, Harwell C, et al. Effective analgesia using physical interventions for infant immunizations. Pediatrics. 2012;129(5):815-822.

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