Analgesic effect of breast feeding in term neonates: randomised controlled trial
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7379.13 (Published 04 January 2003) Cite this as: BMJ 2003;326:13
All rapid responses
Sir,
Carbajal's paper (1) demonstrates the importance of newborn-mother
interaction even as an analgesic. This is a further demonstration of what
we described in our papers (2,3): multisensorial stimulation, offered by
an attentive caregiver, is analgesic in newborns. We gave this phenomenon
a dual explanation:
1. multisensorial stimulation activates gate control
(4) of pain transmission to the brain, creating competition between
painful and non painful stimuli: according with the gate control theory
the brain is not a passive receiver of nociceptive input, but can
influence the information received, deciding whether it is important
enough to record.
2. Newborns are very demanding and want to be
reassured, soothed and calmed [they also need to relate and interact]. We
concluded that we cannot continue considering pain only from the technical
point of view, treating heel-prick or venepuncture only with oral sugar,
sucking and topical analgesics, which only provide partial analgesia and
not almost complete disappearance of pain signs as does multisensorial
stimulation that we showed to be more effective than oral sugar.
Furthermore the technical approach is not ethical because it ignores the
needs of newborns for human presence, preferably the mother. Carbajal's
work is a further demonstration that newborns, including premature babies,
look for a reassuring presence when experiencing pain. This might be
surprising, but to the attentive observer they reveal an unsuspected
emotional world. Not only do they feel pain, but they are also capable of
suffering, distress, anxiety and fear. This needs to be considered in
neonatal analgesic treatment, even for extremely premature children, where
mothers are not always allowed to stay by them: it is mandatory for
caregivers to guarantee a reassuring presence during painful procedures:
newborns are exacting patients. They not only feel pain, they even suffer;
they request not only sugar or drugs, but a human presence nearby.
References:
1. Carbajal R, Soocramanien V, Couderc S, Ville Y: Analgesic effect of
breast feeding in term neonates: randomised controlled trial. BMJ
2003;326:13
2. Bellieni CV, Buonocore G, Nenci A, Franci N, Cordelli DM, Bagnoli F:
Sensorial saturation: an effective tool for heel-prick in preterm infants.
Biol Neonate 2001;80:15-18
3. Bellieni CV, Bagnoli F, Perrone S, Nenci A, Cordelli DM, Fusi M,
Ceccarelli S, Buonocore G: The effect of multi-sensory stimulation on
analgesia in term neonates: a randomized controlled trial. Pediatr Res.
2002 Apr;51(4):460-3
4. Melzack R, Wall PD: Pain mechanisms: a new theory. Science
1965;150(699):971-9
Carlo V Bellieni, MD
Competing interests:
None declared
Competing interests: No competing interests
I cannot speak, but I’ve always used my body movements, my facial
expressions, my beckoning and my cries to make me understand. I’d like to
say that for the past few years (about ten), I’ve been bothered more and
more by all those people who continuously try to separate me from my
mother as soon as I am born. They do not allow me to stay with her more
than a few hours during the day. They do not allow me to suckle that
delicious creamy fluid that they call colostrum. And if they do allow me,
it’s only when they decide. They advise my mother on when and how much I
should eat. Often they do not allow me to drink my mother’s milk, but
rather a liquid that I dare to swallow only because I’m starving. I know
that there are some people out there who try to protect me (1,2), but let
me tell you that they are few, too few!
The worst came when many people round the world started to think that they
had to find proof that my desire to stay close to my mother and to suckle
her milk as I wished, just as any puppy would do, was truly legitimate, in
other words “effective”. They started to carry out the best possible
research, what they call RCT, according to “evidence based medicine”. It
is impossible for me to list all the RCTs they imposed upon me, because
the Editor of the BMJ wouldn’t let me add more than five references. But
if you want, you can type "Breast Feeding" [MESH] in something called
PubMed, you can limit the publication date from 1993 to 2003 and age to
newborn, and search only the RCTs you will count 187 papers!
I’d like to ask you to please stop wasting your time trying to demonstrate
that doing what mother nature does is better than doing something else.
Acknowledgement: I’d like to give many thanks to Sergio Conti Nibali,
family paediatrician, who allowed me to speak out.
1. Editorial. A warm chain for breastfeeding. The Lancet
1994;344:1239-41
2. American Academy of Pediatrics Work Group on Breastfeeding.
Breastfeeding and the use of human milk. Pediatrics 1997;100(6):1035-1039
Competing interests:
None declared
Competing interests: No competing interests
Editor
Caberjal et al. reported that breastfeeding reduced pain during neonatal
procedures like venepuncture1. This article sends the message that in the
name of randomised trials one could readily convert a social concept to
level two evidence.
Planned methods could lead to planned results. How?
1.Exclusion of a group of newborns held by mother during the
procedure and given formula the same way as their breastfed counterparts.
Perhaps it is the skin-to-skin contact2 and sucking of milk (not
necessarily breastfeed) that reduced pain.
2.Types of devices for neonatal venepuncture or number of attempts
per blood sample were not considered. As common devices like venous
cannula, ‘broken needle’, scalp vein (butterfly) needle, vacutte needle,
fixed wing Philip’s needle, vary in their ease and efficacy, perceived
pain could have been influenced. Review3 of existing neonatal venepuncture
methods showed benefits of single wing needle over the modified devices.
3.Two groups of newborns were ‘laid on the table’ and given 1 ml each
of water (as placebo) or 30% glucose solution (sweet, hypertonic,
hygroscopic and possibly not very pleasant to newborn taste buds!) for a
few seconds followed by dry pacifier. Breastfed group had their feeds
continued throughout the procedure while ‘held in mother’s arms’. Perhaps
authors set the scene for widening pain scores among study groups.
BMJ’s contribution - ‘what the study adds is analgesic properties of
breastfeeding’ – a generous summary from the evidence presented.
I am not a bottle-feed activist and rest my case.
References
1.Caberjal R, Veerapen S, Couderc S, et al. Analgesic effect of
breast feeding in term neonates: randomised controlled trial. BMJ 2003;
326:13
2.Gray L, Watt L, Blass EM. Skin-to-skin contact is analgesic in
healthy newborns. Paediatrics 2000; 105(1):E14
3.Philip RK, Beckett M. Neonatal Blood Sampling: time for safer
devices. J Neonatal Nursing 2000; 6:88-89.
Competing interests:
Invented the concept of a purpose-built neonatal venepuncture needle(Philip's needle). The developed product is marketed by Vygon Ltd. and is currently used in the majority of neonatal units in UK&Ireland and many Hospitals in continental Europe.
Competing interests: No competing interests
EDITOR—Carbajal et al. report that breastfeeding is an analgesic.1 They measured pain by behavioural measures. Behavioural measures may not be an appropriate way to measure pain when the infant is distracted by being offered the breast.Sharp increases occur in serum cortisol during painful perinatal procedures.2 3 Gunnar et al. compared the behavioural change with the serum cortisol levels when the infant was given a pacifying device. The pacifier calmed the infant and reduced the behavioural indicators of pain but did not lower the serum cortisol levels, so there was no real pain relief.4
Unfortunately, Carbajal and colleagues did not measure serum cortisol, so we really do not know if the breastfeeding actually provided analgesia or simply calmed the infant. We shall have to wait until the study can be repeated with measurement of serum cortisol.
Physiologic responses to pain are greater in children than in adults.5 Children in hospital have a right to be protected from unnecessary procedures.6 Current methods of pain relief call for avoidance of painful procedures whenever possible with appropriate analgesia/anaesthesia when avoidance is not possible.7
We would prefer that infants and children who need a painful procedure, which cannot be avoided, be given appropriate medication for control of pain.
George Hill
Executive Secretary
Doctors Opposing Circumcision
Suite 42
2442 NW Market Street
Seattle, Washington 98107
USA
Web: http://www.doctorsopposingcircumcision.orgReferences
- Carbarjal R Veerapen S, Couderc S, et al. Analgesic effect of breast feeding in term neonates: randomised controlled trial. BMJ 2003;326:13.
- Talbert LM, Kraybill EN, and Potter HM. Adrenal cortical response to circumcision in the neonate. Obstet Gynecol 1976;46(2):208-210.
- Gunnar MR, Fisch RO, Korsvik S, Donhowe JM. The effects of circumcision on serum cortisol and behavior. Psychoneuroendocrinology 1981;6(3)269-275.
- Gunnar MR, Fisch RO, and Malone S. The effects of a pacifying stimulus on behavioral and adrenocortical responses to circumcision in the newborn. J Am Acad Child Psychiatr 1984; 23(1):34-38.
- Anand KJS, Hickey PR. Pain and its effects in the human neonate and fetus. New Engl J Med 1987;317(21):1321-1329.
- Alderson P. European charter of children's rights. Bulletin of Medical Ethics, October 1993, Pages 13-15.
- American Academy of Pediatrics. Committee on Fetus and Newborn, Committee on Drugs, Section on Anesthesiology, Section on Surgery. Prevention and Management of Pain and Stress in the Neonate. Pediatrics 2000;105(2):454-461.
Competing interests:
None declared
Competing interests: No competing interests
EDITOR-
The study of Carbajal et al strengthens the evidence base of our
neonatal and postnatal ward practices (1). In numerous babies, the only
analgesic ever used by me and my colleagues during sampling has been
concurrent breastfeeding - its remarkable to see the soothing effect of
this procedure against the wishfully avoidable trauma incurred by us
during venepunctures or heelpricks. It would have been interesting to look
at the differences in pain percetion and modulating influences of
breastfeeding in relation to the preprocedure state of awareness as per
Brazelton scale. Differences in an wide alert neonate versus the sleepy
baby are likely.
In setups with poor confidence levels about the environmental
sterility especially in poor developing countreies or primary care setups,
perhaps its prudent to avoid an external source of infection like oral
sucrose solutions or pacifiers. Admittedly poor maternal hygiene and
subsequent breastfeeding is also a potent source of transmission . Yet I
surmise it is better to resort to breastfeeding alone as an analgesic (
with its known share of commensals, to which the neonate is likely to be
accustomed to and hence less likely to progress to sepsis )rather than the
undoubtedly efficacious oral analgesic solutions.
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1. Ricardo Carbajal, Soocramanien Veerapen, Sophie Couderc, Myriam Jugie,
and Yves Ville. Analgesic effect of breast feeding in term neonates:
randomised controlled trial
BMJ 2003; 326: 13
Competing interests:
None declared
Competing interests: No competing interests
the effects is probably due to melatonin in milk
Melatonin is in breast milk and melatonin stimulates beta-endorphin
release.
Competing interests:
None declared
Competing interests: No competing interests