The Effect of Whole Body Massage on Pain Scores

of Neonates During Venous Puncture and

Comparison With Oral Dextrose and Kangaroo Care,
a Randomized Controlled Evaluator-blind Clinical
Study
Hacer Yapıcıoglu Yıldızdaş
Çukurova University
Buket erdem
Çukurova University
Duygu Yıldız Karahan
Çukurova University
FERDA OZLU (  ferdaozlu72@[Link] )
cukurova university
Yaşar Sertdemir
Çukurova University

Article

Keywords: Massage, Kangaroo care, oral 10% dextrose, pain, newborn

Posted Date: August 9th, 2022

DOI: [Link]

License:   This work is licensed under a Creative Commons Attribution 4.0 International License.
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Version of Record: A version of this preprint was published at Journal of Perinatology on November 30th,
2022. See the published version at [Link]

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Abstract
Objective: Newborns in NICUs experience many painful procedures. The aim of the study was to evaluate
the effect of whole body massage therapy on pain scores during venipuncture and compare with oral
10% dextrose and Kangaroo care.

Study Design: Newborns with gestational age ≥34 weeks were randomly enrolled to one of three groups:
massage, dextrose and Kangaroo and a blinded investigator scored the pain using NIPS before and
during the procedure.

Results: There were 25, 26 and 23 newborns in dextrose, massage and Kangaroo care groups,
respectively. Pain scores were similar before and during venipuncture in groups (p> 0.05). 36.5% of
newborns (27/74) had severe pain scores. Number of newborns with no pain (score 0-2), moderate pain
(score 3-4) and severe pain (score 5-7) were similar in each group.

Conclusion: Massage, Kangaroo and oral 10% dextrose had similar effects on pain scores during
venipuncture.

Introduction
Neonates, especially preterm babies, experience a high number of painful procedures in Newborn
Intensive Care Units (NICUs). Structural and functional brain development is vulnerable to procedural pain
(1). Pain is associated with physiological instability such as tachycardia or bradycardia, tachypnea, high
blood pressure and hypoxia in short term and emotional, behavioral and learning disabilities may be
observed in long term (2, 3). For this reason pain should be prevented and treated adequately in all
newborns in NICU.

Nonpharmacological methods such as oral sucrose, glucose or breast milk, non- nutritive sucking,
facilitated tucking, Kangaroo care and massage therapies are used to reduce pain in NICUs as the first
step particularly in minor pain (3–6). Kangaroo care has been used for preterm babies for warmth and
bonding for many years and it has been shown that Kangaroo care decreases crying time, improves pain
scores and decreases stress in neonates during procedural pain (7, 8). Massage and kinesthetic
stimulation improve weight gain in very low birth weight preterm babies (9) and massage and touch
decrease cortisol level and increase growth factors in newborn period (10, 11). Although there are many
studies about sweet solutions use and Kangaroo care for pain relief in newborns (3, 8), there are limited
numbers of studies about local massage and whole body massage prior to injection and pain scoring in
newborns (12–15). In this study we aimed to compare the effects of whole body massage therapy on
Neonatal Infant Pain Scale (NIPS) scores (16) of neonates experiencing venous blood sampling and
compare its effect with Kangaroo care and oral 10% dextrose solution in a evaluator blinded randomized
study.

Subjects And Methods

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The study was done in 1 May- 30 June 2018. Newborns with gestational age ≥ 34 weeks rooming-in with
their mothers in Obstetric Clinic more than two days and newborns in NICU for late prematurity,
hyperbilirubinemia or transient tachypnea of newborn were randomized to one of three groups: Massage
group, Kangaroo care group and 10% dextrose group. Neonates with an Apgar score less than 8 in the
first minute, with major abnormalities, with respiratory distress or treated with oxygen were not included.
The study was approved by the Ethics Committee of Çukurova University.

YS generated a random sequence with three groups and sample size of 81 using a computer (1 block of
size 81). YS used this randomization sequence to place the group allocation into opaque envelopes
numbered 1 to 81. The investigator (FO) was responsible for randomization and talked with parents of
eligible infants about the study. She described the risks, benefits, voluntary participation and procedures.
After written consents were signed, FO opened the envelope and informed the other two investigators (BE
and DYK) about the group of each eligible infant. The investigator BE was responsible for performing
massage, Kangaroo care and dextrose and DYK was responsible for videotaping before (when the baby
was in the incubator) and during blood sampling. In massage group, whole body massage (in prone
position for 30–45 seconds from head-neck-to head, from neck-shoulders-to neck, from neck-spine-
sacrum-to neck, from hip-leg-feet-to hip, and in supine position abdomen and thorax) was performed
using baby oil for 5 minutes and then baby was nested in the incubator. In Kangaroo care group,
newborns were kept skin to skin with their mothers for 5 minutes and then the babies were placed in the
incubator. In dextrose group, 3 ml of 10% dextrose was given orally while the babies were in incubator.
One minute later after massage, Kangaroo care and dextrose apply, all three groups had venous blood
samplings when the baby was quiet and in supine position. If the baby was asleep, no intervention was
done to awake the baby before blood sampling. All blood samplings were done for clinical investigation
either for laboratory tests or screening tests after 3 days of life. If blood sampling was not successful in
the first attempt, the newborn was excluded from the study. Duration of crying during and after blood
sampling was also noted, however if the baby cried more than 180 seconds, other nonpharmacological
interventions such as pacifier or cuddling were performed to calm the baby (by BE). The blinded
investigator (HYY) watched all videotapes and calculated NIPS scores before the procedure and at 15th
second after needle insertion during venipuncture. NIPS includes facial expression, cry, breathing pattern,
arms, legs and state of arousal.

Sample size and Statistical analysis

For the calculation of expected effect size we used information on standard deviation of NIPS score (1.7)
from Suhrabi et al (17). We used a standard deviation of 2.5 which was about 1.5 times 1.7. We
estimated that 25 infants per group would be needed to detect a difference of size 2 (effect size 0.327) in
mean NIPS score between groups, with a two-tailed α = 0.05 and a power = 0.80. We assigned 27 babies
to each group to account for any losses. All babies were analysed by original assigned groups. All
analyses were performed using IBM SPSS Statistics Version 20.0 statistical software package.
Categorical variables were expressed as numbers and percentages, whereas continuous variables were
summarized as mean and standard deviation and as median and minimum-maximum where
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appropriate. The Chi-square test was applied to compare categorical variables between groups. The
paired samples t-test was applied to compare two related (paired) continuous variables (before, after).
For comparison of more than two groups, Oneway ANOVA was used. The statistical level of significance
for all tests was considered to be 0.05.

Results
There were 238 new admissions to NICU during 1 May-30 June 2018 and there were 9 infants rooming-in
with their mothers hospitalized for more than two days. One hundred and twenty seven of 238 newborns
had a gestational age ≥ 34 weeks; however 15 had infection (urinary tract infection, pneumonia, early
neonatal sepsis), 14 had congenital heart disease, 5 had other congenital abnormality, 4 had metabolic
disease, 1 had hypoxic ischemic encephalopathy, 7 had respiratory distress and were on invasive
mechanical ventilation. Of the remaining 81 patients, 6 of them were discharged in the first two days of
life and 3 parents refused the study. Seventy two newborns from NICU and 9 newborns who were
rooming in with their mothers more than three days in Obstetric Clinic were included in the study. There
were 27 newborns in all groups however 2, 1 and 4 newborns in oral 10% dextrose, massage and
Kangaroo care groups were excluded as the first blood sampling attempt was not successful or parental
refuse for videotaping. 74 newborns were included in the study (Flowchart diagram).

The number of patients rooming- in with their mothers were similar in each group. All newborns had
normal physical examination and on full feeding at the time of study. The characteristics of the patients
are shown in Table 1. There were no statistical differences in terms of gestational age, gender, birth
weight, day of life, time of last feeding, feeding with mother milk/formula and venipuncture site between
groups (p > 0.05). NIPS scores before and during venous blood sampling were lower and mean duration
of crying was shorter in oral 10% dextrose group, but it was not statistically significant (p > 0.05).
Although number of sleeping babies in massage group was lower, it was not statistically significant (p =
0. 128), (Table 1). Number of newborns with no pain (score 0–2), moderate pain (score 3–4) and severe
pain (score 5–7) were similar in each group (Table 2). 36.5% of newborns (27/74) had severe pain
scores. As shown in Table 3, 19 infants were sleeping and 55 were awake before venous blood sampling.
NIPS scores and duration of crying were lower during venous blood sampling in sleeping babies; also
they cried shorter compared to awake ones (p < 0.01, p = 0.001 and p = 0.01, respectively).

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 Table 1
Characteristics of the newborn infants in groups
10% dextrose group Massage group Kangaroo group p
n: 25 n: 26 n: 23

mean ± SD mean ± SD mean ± SD

median (min-max) median (min-max) median (min-max)

Birth weight (g) 3206 ± 712 3198 ± 617 3135 ± 469 0.943

3200 (1850–5240) 3015 (2220–4720) 3155 (2180–3835)

Gestational age (weeks) 38.1 ± 1.4 37.9 ± 2.0 37.6 ± 2.3 0.623
38(34–39) 38(34–41) 38(34–41)

Day of life (days) 4.35 ± 1.68 4.73 ± 1.5 4.22 ± 1.24 0.356

4 (3–9) 5(3–8) 4.00

(3–6)

NIPS score 0.28 ± 1.21 0.65 ± 1.77 0.52 ± 1.76 0.243

before procedure 0 (0–6) 0 (0–7) 0 (0–7) 0.994

during procedure 3.60 ± 2.53 3.77 ± 3.37 3.70 ± 3.26

3 (0–7) 4 (0–7) 4 (0–7)

Crying time (sec) 55.5 ± 67.7 67.9 ± 67.2 59.4 ± 14.3 0.874

22.5 (0-180) 56 (0-180) 30 (0-180)

Gender (male) 16 (64) 8 (30.8) 11 (47.8) 0.084

Sleep-awakening state 8 (32) 3 (11.5) 8 (34.8) 0.120

sleeping

Table 2
Neonatal Infant Pain Scale scores of the newborns in groups
during procedure
NIPS 10% dextrose Massage Kangaroo p

n: 25, (%) n: 26, (%) n: 23, (%)

0–2 point 10 (40) 11 (42.3) 9 (39.1) 0.452

3–4 point 8 (32) 3 (11.5) 6 (26.1)

5–7 point 7 (28) 12 (46.2) 8 (34.8)

NIPS 0–2: no pain, 3–4: moderate pain, 5–7: severe pain

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 Table 3
Neonatal Infant Pain Scale scores of sleeping and awaken newborns
Sleeping Awaken p

n:19 n: 55
mean ± SD mean ± SD

median (min-max) median (min-max)

Before procedure NIPS 0.05 ± 0.23 0.64 ± 1.81 0.208

0 (0–1) 0 (0–7)

During procedure NIPS 1.37 ± 1.92 4.33 ± 2.77 < 0.001

0 (0–7) 5 (0–7)

Duration of crying (sec) 25.95 ± 55.74 72.86 ± 66.89 0.001

3 (0-180) 55 (0-180)

Duration of crying n/19 (%) n/56 (%)

Short (0–10 sec) 13 (68.4) 18 (32.8) 0.013

Moderate (11–60 sec) 4 (21.1) 13 (23.6)

Long (61–180 sec) 2 (10.5) 24 (43.6)

Discussion
In the present study, we have shown that all groups showed similar results on NIPS scores during
venipuncture. Although pain scores and crying time were lower in oral 10% dextrose group, it was not
statistically significant. An interesting finding was significantly shorter duration of cry and lower pain
scores in sleeping babies compared to awake ones. As seen in Table 2, 36.5% of newborns had severe
pain scores.

Analgesic effects of sweet solutions have been shown in painful procedures of newborn babies (1, 3, 18,
19). Most of the studies are about sucrose solutions (3), however dextrose is widely found in newborn
units and we use 10% dextrose for pain relief in our unit. In a metaanalysis of 38 RCTs about the efficacy
of nonsucrose solutions, neonates receiving glucose had lower pain scores during heel lances and
venipuncture compared with newborns who received water (19). So glucose seems a good alternative to
sucrose. However glucose concentration used in most of the studies is either 20% or 30%. A higher
concentrated glucose solution may be advantageous for shortening crying time as shown in Deshmukh
and Udani’s study (20) but osmolality of a higher concentration of sugar (24–33%) is up to 1000
mOsm/L which may be harmful especially for preterm babies (21). Also multiple use of sucrose solutions
and 30% glucose raised concerns about poor neurobiological and developmental outcomes. For this
reason we preferred to use 10% dextrose in the present study (1, 21).
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There are a limited number of studies using 10% dextrose in newborns. Bellieni et al (22) showed that
breast milk and 10% dextrose are effective in reducing heel stick pain in preterm infants. Similarly Jatana
et al (23) reported 10% dextrose and expressed breast milk had comparable effects in their analgesic
effects. In another study, Matar et al (24) studied the effect of oral 10% glucose on procedural pain
associated with nasopharyngeal suctioning and venipuncture and found that neonates with placebo
group cried significantly more after the procedures. In a study in preterm babies, pain score was similar in
breast milk and 10% dextrose groups (25). In our study, babies in 10% dextrose group showed similar
NIPS scores.

Kangaroo care is another nonpharmacological intervention for pain control in newborns and there are
many studies comparing Kangaroo care combination with sucrose, dextrose, breastfeeding and
combinations were found to be more effective than Kangaroo care alone for pain scores and crying (8).
One study compared Kangaroo care (n = 640) with and without dextrose and found that Kangaroo care
was more effective than dextrose alone and the combination was the most effective one (26). Pandita et
al (27) reported reduced NIPS scores and crying time in Kangaroo care group during vaccination in
infants less than 14 weeks of postnatal age. In the same study Kangaroo care was more effective than
swaddling. Castral et al (28) showed lower pain scores in preterm babies who received Kangaroo care
before and during heel prick. Johnston et al (7) found similar results in preterm babies in a cross over
design study. However in most of the studies heel-lancing procedure was held while the babies were
remained in Kangaroo care position. As the NIPS score includes the movement of arms and legs and the
investigator evaluating the NIPS scores was blinded, babies were kept in the incubator during the
procedure in the present study.

We compared whole body massage method with oral 10% dextrose and Kangaroo care methods and
found similar effects. Beneficial effects of massage on preterm babies in terms of improving weight gain,
decreasing cortisol levels and increasing growth factors have been reported (9, 10). There are a few
studies about local massage prior to injection and pain scoring in newborns (12–14). In the present study
we preferred whole body massage before venipuncture. Jain et al (12) investigated 2 minutes of
ipsilateral leg massage before heel stick and found lower NIPS score and heart rate compared to control
group. Similarly Chik et al (14) investigated the effect of upper limb massage before venipuncture in a
crossover, randomized controlled trial and found significantly lower pain score in massage group
compared to control group. In the present study we did not have a control group for ethical reasons;
however we have seen that 5 minutes of whole body massage showed similar pain scores with the other
groups.

Although the aim of this study was not to investigate the effect of sleeping on pain score and crying time,
we have found that sleeping babies had statistically significant lower pain scores and shorter crying time.
These findings are really interesting as blood sampling is usually recommended when the infant is in an
awake or drowsy state. Although not statistically significant, awake babies were more in massage group,
probably due to stimulation of the baby during touching. To our knowledge there is only one study
showing similar results. In Grunau and Craig’s study (29) during heel lance awaken term babies showed
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more facial response than those in sleep. The limitations of the study include a small sample size. Also
an additional research may be helpful to investigate the effect of sleep on pain scores in newborns.

In conclusion we have compared effect of whole body massage with oral 10% dextrose or Kangaroo care
and found no statistically significant difference between groups in terms of NIPS scores during venous
blood sampling. Although infants in oral 10% dextrose group had lower NIPS scores and shorter duration
of cry, it was not statistically significant. We can prefer any of these methods for venous sampling. One
of the most important findings of the study is almost one third of the patients had severe pain scores. So
the aim should be to reduce invasive painful procedures and to find optimal methods of managing pain
for infants.

Declarations
The authors report no conflict of interest
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