The Effect of Swaddling on Pain, Vital Signs, and Crying Duration During Heel Lance in Newborns

Zeynep Erkut, MSc, RN; Suzan Yildiz, PhD


Pain Manag Nurs. 2017;18(5):328-336. 

In This Article

Abstract and Introduction


To determine the effect of swaddling on pain, vital signs, and crying duration during heel lance in the newborn. This was a randomized controlled study of 74 (control: 37, experiment: 37) newborns born between December 2013 and February 2014 at the Ministry of Health Bagcılar Training and Research Hospital. An information form, observation form, and Neonatal Infant Pain Scale were used as data collection tools. Data from the pain scores, peak heart rates, oxygen saturation, total crying time, and duration of the procedure were collected using a video camera. Newborns in the control group underwent routine heel lance, whereas newborns in the experimental group underwent routine heel lance while being swaddled by the researcher. The newborns' pain scores, peak heart rates, oxygen saturation values, and crying durations were evaluated using video recordings made before, during, and 1, 2, and 3 minutes after the procedure. Pain was assessed by a nurse and the researcher. No statistically significant difference was found in the characteristics of the two groups (p > .05). The mean pain scores of swaddled newborns during and after the procedure were lower than the nonswaddled newborns (p < .05). In addition, crying duration of swaddled newborns was found to be shorter than the nonswaddled newborns (p < .05). The average preprocedure peak heart rates of swaddled newborns were higher (p < .05); however, the difference was not significant during and after the procedure (p > .05). Although there was no significant difference in oxygen saturation values before and during the procedure (p > .05), oxygen saturation values of swaddled newborns were higher afterward (p < .05). For this study sample, swaddling was an effective nonpharmacologic method to help reduce pain and crying in an effort to soothe newborns. Although pharmacologic pain management is the gold standard, swaddling can be recommended as a complementary therapy for newborns during painful procedures. Swaddling is a quick and simple nonpharmacologic method that can be used by nurses to help reduce heel stick pain in newborns.


During the neonatal period, which covers the first 28 days after birth, newborns try to adapt themselves to the environment with biochemical and physiologic changes that involve all body systems (Pappas & Walker, 2010). During the adaptation process into the extrauterine environment, healthy newborns undergo medical interventions such as hepatitis B vaccination, vitamin K injection, blood sugar level monitoring, and screening for bilirubin or metabolic diseases (Joffe et al., 2009, Krishnan, 2013, Nicolet et al., 2010). The diagnostic heel lance is one of the most common medical interventions conducted in newborns (Cong et al., 2009, Hummel and Puchalski, 2001, Stevens et al., 2003). Carbajal et al. (2008) conducted a study in France with newborns (N = 430) and reported that nearly one fifth of the medical interventions made for the newborns (19.8%) were composed of heel lance. It is known that heel lance causes increased pain, peak heart rates (PHRs), and blood pressure, along with decreased oxygen saturation (SpO2) and crying (Gardner et al., 2006, Krishnan, 2013, Prasopkittikun and Tilokskulchai, 2003).

Nonpharmacologic methods are valuable interventions to supplement pharmacologic management of pain (Czarnecki et al., 2011). Nonpharmacologic methods do not necessarily control pain but distract the newborn from the negative effects of the pain experience. Among the most commonly used nonpharmacologic techniques are those that reduce environmental stimuli and provide individualized developmental care, methods such as music therapy, breastfeeding, non-nutritive sucking, sucrose and sweet solutions, massage and touching, positioning, holding, containment, kangaroo care, and swaddling (Caglayan, 2011, Clifford et al., 2004, Cong et al., 2009, Efe, 2003, Karaayvaz, 2009, Krishnan, 2013, Nicolet et al., 2010, Yamada et al., 2008). In addition to this variety of methods, swaddling, which contains the newborn's limbs close to its trunk in a flexed position, as long as it is appropriate for the anatomic position of the newborns, is one of the most commonly used nonpharmacologic methods for attempting to decrease the negative effects of invasive interventions (Karp, 2008, Meek and Huertas, 2012, Mosiman and Pile, 2013).

There are many positive effects of swaddling for newborns. Swaddling reduces physiologic and behavioral stress, shortens the time to falling asleep, helps newborns to sleep uninterruptedly, prevents spontaneous waking, and shortens crying duration (Ramachandran and Dutta, 2013, van Sleuwen et al., 2006). Also, swaddling helps them spend less energy by enabling newborns to experience less stress during bathing, prevents hypothermia by assisting thermo regulation, positively affects neuromuscular and motor development, facilitates newborns' adaptation to the extrauterine environment, decreases sudden infant death syndrome (SIDS), and regulates peak heart rates and oxygen saturation by relieving pain caused by invasive interventions (Mosiman and Pile, 2013, Quraishy et al., 2013, van Sleuwen et al., 2007). In the limited number of studies in which swaddling was used during heel lance, it was reported that swaddling helped newborns to experience a significant decrease in pain, helped regulate peak heart rates and oxygen saturation, and shortened crying duration (Huang et al., 2004, Kacome, 1996, Morrow et al., 2010, Prasopkittikun and Tilokskulchai, 2003, Shu et al., 2014, Sinpru et al., 2009, Srithong, 2002). Tantapong (2000) studied the effects of swaddling on pain responses to heel stick in 30 premature newborns (between 32 and 35 completed weeks of postconceptual age) in a quasiexperimental study. All newborns were observed twice (swaddled and unswaddled) in 2 consecutive days. The newborns were swaddled by a researcher, then swaddling and video recording were performed for 3 minutes before the procedure, during the procedure, and for 5 minutes after the procedure. The results revealed that swaddling significantly reduced the heart rate response to pain and pain scores of preterm newborns after heel stick.

An interprofessional team approach is required in pain management of newborns, and nurses are key members of this team (Anand and International Evidence-Based Group for Neonatal Pain, 2001, Hutchinson and Hall, 2005). The objective in pain management of newborns is to help newborns cope with pain and stress caused by clinical procedures, to reduce or to eliminate pain, and to prevent negative effects that can occur as a result of pain (Walden, 2010). Therefore, nurses should routinely and objectively assess newborns' pain using pain scales before and after medical interventions, and support newborns who experience pain with pharmacologic and nonpharmacologic methods (Gardner et al., 2011, Karaayvaz, 2009, Van Marter and Pryor, 2008).