Do The 5 S’s Relieve Pain Of Vaccines?

by Heidi Green
May 05, 2012

For young children, it can seem that just about every trip to the doctor involves pain or fear. If they’re not seeing the doctor for injury or illness, they’re there for well visits, which often involves the pain or fear of a shot. The Centers for Disease Control and Prevention’s (CDC) current immunization schedule calls for more than a dozen separate shots (injections) before the age of 2. While these injections are given to help prevent diseases, they can sometimes be hard to bear.

Still, in spite of the distress immunizations cause for children, parents, and health care providers, they’re widely accepted as a necessary part of preventive care. A recent study suggests that although childhood shots may be unavoidable, the pain they cause may be reduced by applying a set of strategies known collectively as “the 5 S’s”.

“Happiest babies” know 5 S’s
“The happiest baby on the block” is what Dr. Harvey Karp promises you’ll have if you apply his “5 S” approach to baby-calming, which has become the basis for a complete line of books, videos, and training products (and even a “happiest toddler” spin-off).

This strategy involves five steps—swaddling, side/stomach position, shushing, swinging, and sucking—delivered in a prescribed order. The steps must be delivered just so, according to Dr. Karp’s website, which asserts that the steps trigger a “calming reflex” and that while “centuries” of parents “have tried these methods,” they have “fail[ed] because … the calming reflex only works when it is triggered in exactly the right way.” [emphasis Karp’s]

The literature on Karp’s approach is sparse, and one recent study found the video training to be ineffective in reducing infant crying. Still, the program continues to draw attention for its baby-calming potential.

Could vaccinated babies be “happiest babies”?
For the purposes of this research study, a team led by pediatrician Dr. John Harrington of the Eastern Virginia University Medical School sought to assess the “analgesic, pain-relieving effectiveness of using [the 5 S’s] … during routine immunizations given to infants at 2 and 4 months of age.”

The researchers tested Karp’s strategies both alone and in combination with a small amount of sucrose (sugar water), which is itself widely recognized for its pain-relieving properties and recommended by an international committee of pediatricians.

Study participants included 230 infants during their 2- or 4-month well-child visit. None had received acetaminophen or ibuprofen within four hours of receiving their immunization. Participants were predominantly urban, Medicaid-enrolled, and African American. Nearly three-quarters were 2 months old at the time of the survey. All injections were given with the infants lying on the examination table.

Infants were randomized into one of four groups:

1. Group 1 (water only) received 2 ml of water two minutes before immunization. (Water has no analgesic quality, but was administered so that study participants and researchers would not be biased by knowledge of whether or not the child received sucrose.) Parents were able to comfort the babies in this group immediately after immunization.
2. Group 2 (sucrose only) received 2 ml of sucrose two minutes before immunization. Parents were able to comfort the babies in this group immediately after immunization.
3. Group 3 (S’s only) received 2 ml of water two minutes before immunization. A study researcher initiated Karp’s strategies immediately after immunization.
4. Group 4 (sucrose and S’s) received 2 ml of sucrose two minutes before immunization. A study researcher initiated Karp’s strategies immediately after immunization.

The researchers responsible for administering the 5 S’s learned the approach by watching a video, and practiced swaddling until they could wrap a baby in 15 seconds or less.

Those in groups 3 or 4, who were to be calmed by the researcher, were immediately swaddled. They were held in the side/stomach position with shushing and swinging/swaying, and offered a pacifier (for “sucking”) at 30 seconds. Many babies refused pacifiers, some because their parents had chosen not to use them (you can read more on the pacifier controversy here), but researchers were required to use at least four of the five S’s.

Assessing infant response
Babies’ responses were assessed using a pain scale that assigned numeric scores to three types of behaviors: verbal (no cry, whimpering/complaining, pain crying, screaming/high-pitched cry), facial (neutral/smiling, frowning/grimacing, clenched jaw/mouth, full cry expression), and body movement (calm/relaxed, restless/fidgeting, moderate agitation or mobility, thrashing/flailing or voluntary immobility). Babies’ behavior was scored every 15 seconds for the first two minutes, and then every 30 seconds until five minutes post-vaccination.

Four of the five S’s were completed by researchers for all of the intervention (groups 3 and 4) babies. No data were collected on comfort strategies employed by parents in the non-intervention (groups 1 and 2) babies.

Study findings
Not surprisingly, Harrington and colleagues found that the mean pain score was highest for the water-only group. The scores of the sucrose-only group were also higher than those of the “5 S” groups. The lowest mean pain scores were reported for the group that received both sucrose and the “5 S” strategies.

The researchers write that “the 5 S’s appear to be a viable option for clinics to implement when providing analgesia.” However, this study should be read with caution for several reasons:

1. Parent behavior is unknown. Researchers did not track the calming behaviors used by the parents in the non-intervention groups. It is probable that some parents incorporated some of the studied behaviors (swaying, shushing, swinging) with their babies.
2. Baby calming may have been a function of “who” rather than “what.” Some research suggests—as surprising as it may be—parents may be the least effective “calmers” of their children during vaccinations, since they tend to focus on reassurance rather than distraction.
3. Assessment included “body movement” even though swaddled babies—those in the intervention, 5 S groups—are hardly capable of free movement. As a result, the researchers may have overestimated pain response in unswaddled babies. Other research on infant pain has measured factors such as heart rate variability and salivary cortisol levels, in addition to crying time and behavior.
4. The 5 S approach seems counter to other, well-researched calming methods, such as breastfeeding, kangaroo care, facilitated tucking, and pressure at the injection site.
5. The infants in this study were all laid down on the exam table for their injections, a position which may unnecessarily heighten their anxiety before the first jab occurs.
6. The 5 S process is time-consuming. The researchers note that topical anesthetics are “generally not used in a busy practice” because of expense and time, making the 5 S approach especially untenable in light of the researchers’ observation that the approach was more difficult to implement with the “bigger and heavier” 4-month-olds.

Ultimately, Harrington and colleagues call for further research on this approach, and this seems warranted. Research into use of the 5 S’s during vaccination by parents themselves would be helpful, since this strategy may be both unnatural to many parents and difficult for them to implement during the stress of vaccination. Given the small number of 4-month-olds included in this study, research into use of this approach with older infants also would be appropriate.

Tips for relieving vaccination pain
In light of this research, what can parents do to alleviate their babies’ distress during vaccinations?

• Breastfeed! Harrington and colleague note that research shows breastfeeding combines several analgesic effects “(a comforting person [mother], skin-to-skin contact, diversion of attention, and the sweetness of lactose)” as effective for procedural pain. They do not recommend the “5 S” approach when breastfeeding is an option.
• Distract and stimulate! It’s possible that Karp’s “5 S” approach appears to work because it fully consumes the baby’s attention. Parents can do that without following a step-by-step routine.
• Hang tight! Immunizations are an annoyance, but they’re an important part of building a child’s immune system and reducing their risk of contracting a vaccine-preventable disease. If you have any concerns, talk to your child’s pediatrician; otherwise, rest assured—you’ll get through this.

Above all, trust your instincts. Vaccinations can be difficult for babies and parents alike, but by responding to your baby with support and distraction—with or without a 5 S instructional—you’ll likely succeed in calming both your baby and yourself.