Nonpharmacological Management of Procedure-Related Pain in the Breastfeeding Infant

Publication Date: November 1, 2016
Last Updated: March 14, 2022


Breastfeeding or human milk

Breastfeeding should be the first choice to alleviate procedural pain in neonates undergoing a single painful procedure, such as venipuncture or heel lance. (IA)
Breastfeeding should not be discontinued before the procedure. (IB)
When breastfeeding is not possible, whether because of the unavailability of the mother or difficulties with breastfeeding, expressed human milk given by dropper, syringe, or bottle has been shown to soothe newborns experiencing procedural pain. (IA)
Breastfeeding throughout the painful procedure is likely to be superior to human milk alone on the basis of synergism between the components of breastfeeding. (IB)

Skin-to-skin contact

Coordinating a breastfeeding session with the timing of the procedure is best, but, if this is not possible, skin-to-skin contact with the mother or other caregiver can comfort infants undergoing a procedure such as a heel lance. (IA)
Parental contact and sucrose may act synergistically to reduce pain in neonates. Therefore, if feasible, this combination can be employed. (IB)

Warmth and scent

Two studies evaluating the effects of warmth on infant pain associated with immunization found a significant analgesic effect when used as the sole intervention and when used in concert with administration of a sucrose solution. Infants received 2 minutes of radiant warmer exposure, which was shown not to affect infant core temperature. This maneuver may be a safe and easy intervention if skin-to-skin contact or breastfeeding is not available. (IB)
The scent of human milk and various other substances such as lavender, vanilla, formula, and amniotic fluid has been evaluated as possible analgesics for painful procedures in preterm and full-term infants, with human milk consistently found to be effective at reducing pain. (IB)

Sucrose and Sucking (in Combination or Separately)

Sucrose taste has been shown to be an effective analgesia for newborns and young infants for many minor procedures but not for more lengthy or invasive procedures such as circumcision 32 or bladder catheterizations in infants older than 30 days. When breastfeeding infants are undergoing painful procedures without mother available for direct breastfeeding and when expressed human milk is not available to use as a supplement, use of sucrose and sucking may be considered. (IA)

Sucrose and pacifier

Because pain reduction achieved when using both sucrose and non-nutritive sucking is similar to that with breastfeeding, using a pacifier dipped in 24% sucrose (by weight) solution whenever breastfeeding is not possible is an effective option. (IB)
Sucrose administration should begin 2 minutes before the procedure. (IB)

Sucrose by syringe

If sucking a pacifier or finger is not an option, 0.5–2mL of a 24% sucrose solution can be administered orally through syringe 2 minutes before the painful procedure. (IB)

Glucose versus sucrose

Glucose has also been shown to be an acceptable and effective alternative analgesic. (IB)

Sucrose better than human milk?

At least one small study indicates that sucrose is significantly more effective than human milk, when both are administered orally through syringe, at reducing infants’ cry time, recovery time (heart rate peak returns to baseline), and change in heart rate. (IB)

Pacifier alone

A pacifier (or clean gloved or parental finger) should be used as the sole soothing intervention only if breastfeeding, human milk, sucrose (or glucose), and skin-to-skin contact are unavailable. (IB)

Soothing the Preterm Newborn

Breastfeeding may be difficult secondary to the medical status of the infant. Preterm infants may bemedically compromised and/or may be developmentally unable to suck or swallow. In such cases, individual components of breastfeeding or a combination of the components (e.g., contact and sweet taste) is available. (IB)
Skin-to-skin contact provides effective pain reduction for preterm newborns. (IB)
In very-low-birth-weight neonates (27–31 weeks gestation) undergoing consecutive heel lances, a pacifier dipped in sucrose or water significantly reduced pain compared with infants who did not receive any intervention. (IB)
The value of sucrose as a pain reducer in the preterm infant is well established. (IB)
Further pain reduction can be achieved when preterm infants receive 24% sucrose as three doses (0.1 mL, 2 minutes apart given 2 minutes and immediately before heel lance and 2 minutes after lance) rather than as a single dose. (IB)
Certainly if a mother wishes to breastfeed or provide her preterm infant with human milk instead of using other interventions, this should not be discouraged. (IB)
Scent of human milk has been found to be an effective analgesic in the preterm infant undergoing venipuncture and heel lance procedures and may be considered in conjunction with other analgesic techniques. (IB)
Skin-to-skin contact plus sucrose has not been formally evaluated in preterm infants, but may provide pain reduction for the preterm or low-birth-weight neonates. (IV)


Two meta-analyses of 10 and 14 randomized clinical trials on infant pain found sucrose to be an effective pain management strategy for infants up to 12 months of age. (IA)

Maternal/caretaker behavior

Giving parents a caretaking role, such as securing or distracting the child, can reduce parental sense of helplessness. When parents are unavailable or unable to play a caretaking role, consider enlisting another healthcare provider to help secure and/or distract the child. (IV)


Although the efficacy of breastfeeding and human milk as a pain reducer for older infants has not been extensively studied, there is potential benefit/ minimal risk. Therefore, mothers who are breastfeeding should be invited to breastfeed the infant during painful procedures. (IV)

Older than 12 months

The upper age limit of effectiveness of sucrose as a pain reducer has not been fully studied, and sucrose, therefore, cannot be recommended as a pain reducer in children older than 12 months at this time. (IA)
A publication of workshop proceedings reviewing the evidence for other techniques such as physical, psychological, and pharmacological interventions shows a range of nonpharmacological treatments to be effective at reducing older childhood vaccine injection pain. (IA)

Recommendation Grading




Nonpharmacological Management of Procedure-Related Pain in the Breastfeeding Infant

Authoring Organization

Publication Month/Year

November 1, 2016

Last Updated Month/Year

June 9, 2022

Document Type


External Publication Status


Country of Publication


Document Objectives

Provide healthcare professionals with evidencebased guidelines on how to incorporate nonpharmacological or behavioral interventions to relieve procedure-induced pain in the breastfeeding infant.

Inclusion Criteria

Female, Adult, Infant

Health Care Settings

Ambulatory, Emergency care, Home health, Hospital, Outpatient

Intended Users

Nurse midwife, nurse, nurse practitioner, physician, physician assistant


Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D064186 - Prenatal Education, D007363 - Intensive Care Units, Neonatal, D015931 - Intensive Care, Neonatal


Breastfeeding, neonate pain, procedural neonatal pain, infantile procedure, holistic neonatal pain management

Source Citation

Reece-Stremtan, S., & Gray, L. (2016). ABM Clinical Protocol #23: Nonpharmacological Management of Procedure-Related Pain in the Breastfeeding Infant, Revised 2016. Breastfeeding Medicine, 11(9), 425–429. doi:10.1089/bfm.2016.29025.srs 

Supplemental Methodology Resources

Data Supplement


Number of Source Documents
Literature Search Start Date
January 1, 1995
Literature Search End Date
December 31, 2016
Description of External Review Process
The draft protocol is peer reviewed by individuals outside of contributing author/expert panel, including specific review for international applicability. The Protocol Committee's sub-group of international experts recommends appropriate international reviewers. The Chair and/or protocol resource person institutes and facilitates this process. Reviews are submitted to the committee Chair and resource person. The contributing author/expert panel and/or designated members of protocol committee work to amend the protocol as needed. The draft protocol is submitted to the Academy of Breastfeeding Medicine (ABM) Board for review and approval. Comments for revision will be accepted for three weeks following submission. The Chair, resource person and protocol contributor(s) amend the protocol as needed. Following all revisions, the protocol has the final review by original contributor(s) to make final suggestions and ascertain whether to maintain contributing authorship. The final protocol is submitted to the Board of Directors of ABM for approval. A two-thirds majority of Board members' positive vote is required for final approval.
Specialties Involved
Critical Care, Family Medicine, Pediatrics, Neonatology And Perinatology, Pediatric Emergency Medicine, Pediatric Surgery, Pediatrics, Pediatrics, Pediatrics
Description of Systematic Review
Expert Consensus from systematic reviews with evidence tables.
Description of Search Strategy
Yes. Inclusion: age, sucrose, psychology – and more.
Description of Study Selection
Yes. Age range – and more. Consensus based.
Description of Evidence Analysis Methods
General Methods An initial search of relevant published articles written in English in the past 21 years in the fields of medicine, psychiatry, psychology, and basic biological science is undertaken for a particular topic. Once the articles are gathered, the papers are evaluated for scientific accuracy and significance. Specific Methods The search was conducted using PubMed. In addition, a search of the original references and literature searches (from the previous version) were used to look for additional supportive articles. The time frame for the literature search was January 1995 to December 2016. The inclusion criteria used for the searched were: humans, review articles, primary research articles, and English. The specific search terms used were: breastfeeding, primary care, physician, pediatrician, obstetrician, family physician.
Description of Evidence Grading
U.S. Preventative Services Taskforce Recommendations. An expert panel is identified and appointed to develop a draft protocol using evidence-based methodology. An annotated bibliography (literature review), including salient gaps in the literature, is submitted by the expert panel to the Protocol Committee.