Infant Vaccs Pain

Relieving the Pain of Infant Vaccinations

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As if the whole subject of vaccinating infants isn’t prickly enough, it’s complicated by the fact that vaccinations hurt! In fact, parents cite the pain and crying as the most important reason they don’t have their children vaccinated.[1] Providers are also more reluctant to give all of the required vaccinations if more than three or four are necessary at one time.[2] While many clinicians provide an analgesic such as acetaminophen or ibuprofen diluted in a sugar solution before or after the injection, recent data suggest that acetaminophen might reduce the antibody protection in several of the vaccines[3]; therefore, there is interest in providing nonpharmacologic pain relief in this young population.

A new study published online in Pediatrics suggests that a simple, well-known comfort intervention can reduce pain and parental anxiety for little ones receiving their immunizations. The popular intervention, known as the 5 S’s, comprises swaddling, side/stomach position, shushing, swaying, and sucking on a pacifier.[4] The intervention, popularized by pediatrician Dr. Harvey Karp, is supposed to mimic the sensation of being in the womb.

The study included 230 infants coming in for their 2- or 4-month vaccinations during routine well-child visits, at which time they typically receive at least three shots (2-month visit) and two shots (4-month visit). Among the babies, 81% were black, 73% were boys, and 73% were 2 months old.

Before the shot, the babies were randomized to one of two groups (2 mL water or 24% oral sucrose). Within 15 seconds of the injection, they were then randomized to be comforted by their parents or to receive the 5 S’s intervention from a medical resident member of the research team (physical intervention). A parental comfort-only group served as the control.

The researchers used the Modified Riley Pain Score (cry quality, grimace, movement) to assess the infants’ pain every 15 seconds for 2 minutes, and subsequently every 30 seconds for up to 5 minutes after the vaccination. Pain scores over the first 2 minutes were lower for all the groups compared with controls, with the average scores on the modified Riley scale:

  • Lowest at 3.24 with the physical intervention alone
  • 3.61 with the physical intervention plus sucrose
  • 3.95 with sucrose only
  • 4.46 with parental comforting only

Of note is that the 4-month-old babies were less likely to benefit from the intervention. But overall, the researchers found that using the 5 S’s consistently produced the lowest pain scores, regardless of whether the infants were given sugar water before their shots. The residents were usually able to perform at least four of the 5 S’s, although there was some variation of the technique among the residents. The most crucial step appeared to be the swaddling, which showed the greatest variation among the residents; the least important step appeared to be giving the babies a pacifier.

The researchers conclude that “the 5 S’s appear to be a viable nonpharmacologic option for clinics to implement when providing analgesia during vaccinations.” And in addition to minimizing suffering, pain control during immunizations may calm parents who are hesitant to have their children vaccinated—an extra-added benefit!


Jill Shuman, MS, ELS
Published April 19, 2012



  1. Jacobson RM, Swan A, Adegbenro A, et al. Making vaccines more acceptable— methods to prevent and minimize pain and other common adverse events associated with vaccines. Vaccine. 2001;19(17-19):2418-2427.
  2. Reis EC. Multiple scheduled injections contribute to missed opportunities to immunize during well care visits. Ambulatory Child Health. 1997;3(1):172.
  3. Prymula R, Siegrist CA, Chlibek R, et al. Effect of prophylactic paracetamol administration at time of vaccination on febrile reactions and antibody responses in children: two open-label, randomised controlled trials. Lancet. 2009;374(9698):1339–1350.
  4. Harrington JW, Logan S, Harwell C, et al. Effective analgesia using physical interventions for infant immunizations [published online ahead of print April 16, 2012]. Pediatrics. doi: 10.1542/peds.2011-1607.