Effect of White Noise in Relieving Vaccination Pain in Premature Infants

Sibel Kucukoglu, RN, PhD; Aynur Aytekin, RN, PhD; Ayda Celebioglu, RN, PhD; Arzu Celebi, RN, MSc; Ibrahim Caner, MD; Rukiye Maden, RN


Pain Manag Nurs. 2016;17(6):392-400. 

In This Article

Abstract and Introduction


The purpose of this study was to evaluate the effect of white noise as a distraction method in relieving procedural pain caused by vaccination for premature infants. This experimental study was performed at a neonatal intensive care unit (NICU) of a university hospital in Turkey between July and September 2013. The study population was composed of 75 premature infants (35 in the study group and 40 in the control group) who met the inclusion criteria. Premature infants in the study group were exposed to white noise using MP3 players placed at the head of the infants' open crib for 1 minute before vaccination. The white noise continued until 1 minute after vaccination. Premature infants in the control group were not exposed to white noise. The Premature Infant Information Form, Intervention Follow-up Form, and Premature Infant Pain Profile (PIPP) were used to collect study data. Descriptive statistics, chi-square test, and independent sample t-tests were used to evaluate the data. The pain level of the control group (PIPP = 14.35 ± 2.59) was significantly higher than the pain level of the study group (PIPP = 8.14 ± 3.14) (p < .05). The authors found that 67.6% of the infants in the study group had moderate pain during vaccination and only 2.9% had severe pain. Most of the infants in the control group (82.5%) had severe pain, whereas 17.5% had moderate pain (p < .05). White noise was found to be effective for this sample; however, there is a dire need for extensive research on white noise and its use with this vulnerable population.


Pain is a special sensation that has both psychological and sensory aspects (Ovalı, 2008). It has been determined in various studies that pain is felt beginning in intrauterine life, and that a fetus can respond to pain beginning at 20–24 weeks of pregnancy (Anand & Phill, 2001; Velde, Jani, Buck, & Deprest, 2006). It is known that the anatomical, neurophysiological, and hormonal development needed to feel pain is complete and that neurotransmitter functions are highly developed in fetuses by late pregnancy. It also is reported that premature infants remember recurrent painful stimuli that occur in the early period and that they show an excessive response to these stimuli at later times (Ok, 2012).

Hormonal, metabolic, cardiorespiratory, and behavioral changes occur in response to pain. The most important problem encountered when assessing pain in premature infants is the lack of verbal expression of the pain response. In measuring pain in infants, one should especially pay careful attention to nonverbal signs (Johnston et al., 2003; Ommaty, 2009). The presence and degree of pain and the response to treatment are evaluated by interpreting certain changes. Premature infants have physiological responses such as increased heart rate, increased blood pressure, increased respiratory rate, decreased oxygen saturation, and paleness or redness in response to painful stimuli (Collins, 2003; Karaayvaz, 2009). Premature infants also show a behavioral response to pain in the form of body movements, facial movements, and crying (Choonara, 1998; Collins, 2003).

Premature infants often spend the first few weeks of life in the neonatal intensive care unit, where they experience pain and stress because of countless different reasons, and where they are exposed to many invasive procedures. The painful procedures in this period negatively affect the behavior of premature infants, adaptation to the external world, development of the brain, growth, and family–baby interaction (American Academy of Pediatrics, 2006; Committee on Fetus and Newborn, Committee on Drugs, Section on Anesthesiology, Section on Surgery and Canadian Paediatric Society, Fetus and Newborn Committee, 2000; Gilad & Arnon, 2010; Johnston et al., 2003).

The goal in pain management of premature infants is to prevent the pain felt by infants who have faced painful procedures since the first moments of life, and to help them cope with that pain. One of a nurse's primary responsibilities is to identify and ease pain correctly, as well as to ensure pain relief with methods applied during routine invasive procedures (American Academy of Pediatrics, 2006; Tamez and Silva, 2013). In line with this goal, pain in the neonate can be managed with effective care given through pharmacological and nonpharmacological means specific to the individual, after thorough and correct assessment (American Academy of Pediatrics, 2006; Karaayvaz, 2009).

A variety of senses, such as vision, hearing, touch, and taste, are used in nonpharmacological methods for diverting attention to reduce pain in premature infants (Cignacco et al, 2007). Music is a highly effective stimulus in neonatal pain relief. Audio stimulation effectively distracts a baby and provides pain control and a cognitive strategy to suppress the pain response (Aydın & Yıldız, 2012).

The sound referred to as white noise or white sound is a continuous, monotone sound in the form of resonance that suppresses disturbing sounds coming from the outside environment and that has a soothing quality (Balcı, 2006). Given these characteristics, white noise is similar to the sounds in the mother's womb. It is known that while still in the womb, the infant is affected by the mother's heartbeat, and being exposed to these familiar sounds and rhythms after birth has a soothing effect on the infant (Balcı, 2006; Ovalı, 2005; Standley, 2001). There is evidence in the literature confirming that intrauterine sounds have stress-reducing, anxiety-reducing, pain-reducing, and soothing effects on the fetus/infant and that its physiological state is positively affected by such sounds (Balcı, 2006; Karakoç & Türker, 2014; Ovalı, 2005). In the study of Balcı (2006) (N = 30), it was determined that white noise had a positive effect on nutrition and sleep, and duration of crying decreased among infants in the group exposed to white noise. In an experimental study (Karakoç & Türker, 2014) about effect of white noise and holding on the pain sensation of newborns (N = 120) whose blood was drawn from the heel, the babies were divided into three groups. In the group I, babies were only held. The babies in group II both were held and listened to white noise. The babies in group III were lying down and only listened to white noise. The results of the research showed that the shortest period of crying during the painful procedures was noted in the group III newborns, who had only listened to white noise. In the another study about the effect of white noise on sucking success in newborns, newborns in the experimental group (n = 63) were made listen to white noise on the first breastfeeding after birth and one more time 24 hours later, and their sucking success was evaluated. The results of the study determined that white noise listening by newborns in the early postpartum period increased their sucking success compared with infants in the control group (n = 64) (Akca & Aytekin, 2014). Based on this information, this study was carried out to investigate the effect of white noise in easing the pain caused by vaccinations in premature infants who receive treatment in the neonatal intensive care unit.