University of Michigan Health System

Your Child

Pain and Your Infant: Medical Procedures, Circumcision and Teething

What is pain?

Pain is an uncomfortable sensation, or feeling. It can be constant (always there) or intermittent (coming and going). Pain can be dull and aching, sharp, or throbbing. It can be both physical and mental, and every infant experiences it differently.

What causes pain?

Babies feel pain when their brains send out special signals to their bodies. Usually, they are sick or injured when their brains send these signals. Feeling pain is a signal that something is wrong. There are many causes of pain in babies. There are the typical ones, like colic, circumcision, teething, and vaccine (immunization) shots. Some babies may have health problems and may experience pain as part of their disease process or painful treatments.

Do newborns experience pain? How does pain affect babies?

Everyone can feel pain, including infants. Even premature babies can feel pain. Newborns experience pain and should receive relief. Pain affects babies' nervous systems [1] in many ways, even changing the structure and physiology of the nervous system. Pain can cause medical complications, and problems with sleep, feeding, and self-regulation. It can also make kids hypersensitive or insensitive to pain later in life, or lead to chronic pain and other problems later on.

What are signs that my baby is in pain?

Because little babies can't tell you anything about how they feel, doctors and nurses are using new tools to help define pain in the babies they care for. Talking to your child's doctors and nurses about pain is important. The more they know about your infant's pain, the more they can help. Infants give certain behavioral signals when they are hurting:

Crying—Your baby's cry may be more insistent, higher pitched, and may last longer than usual. If your baby is very ill or premature, they may not have the energy to cry, so may be quiet even though they are in pain.
Making faces—Your baby may grimace, open their mouth, wrinkle their brow, have deep lines around their nose and squeeze their eyes shut.
Body posture and movement—Your baby's body may be tense or stiff, with the arms and legs either pulled in or all stretched out. Your baby may be squirmy and move their arms and legs in and out. If they are premature or very frail or ill, they may be quiet or floppy, with low muscle tone—and may even withdraw and seem to be sleeping.
Irritability—Your baby may be fussy, restless and off their usual schedule, refusing to eat or sleep. Your baby may not be calmed by comforting or feeding.

Measuring pain in babies is difficult. Changes in vital signs (heart rate, breathing rate, and blood pressure), the amount of oxygen in the blood, and the baby's facial expression and behavior are most widely used to rate infants' pain. The doctors and nurses caring for your baby should take regular measurements of your baby's pain, and record the results in the medical chart. If your baby is in pain, the pain needs to be treated.

There are different pain rating scales used for infants, such as the FLACC Scale (FLACC stands for face, legs, activity, cry, consolability), and theRiley Infant Pain Scale. These pain rating systems look at the baby’s behavior to determine the level of pain.
Pain in Infants (also available in Spanish, Hmong and Somali) has good descriptions of how a baby in pain behaves, as well as useful suggestions for comfort measures.

How can parents help infants in pain?

Hold your child—with as much skin-to-skin contact as possible.
Distract your baby with movement, sucking, music, toys, talking, rocking or singing.
Breastfeed—it may just be the perfect pain reliever [2], for simple procedures, according to a recent review of research studies [3]. Nursing your baby involves holding, skin-to-skin contact, sucking, and a sweet taste. These are all proven ways to reduce the pain a baby feels—combined in one convenient package.
As an alternative to breastfeeding, give your baby a sugar solution (but never honey—it can cause botulism in babies under one year old) on a pacifier.
Your doctor can tell you about proper dosing of acetaminophen (Tylenol) or ibuprofen (Advil or Motrin) for your baby, or other medicines to help relieve pain.

Will my baby become addicted to pain medication?

If your baby is in the hospital for a longer time, you may worry about them becoming addicted to the pain medicine. Don't worry: your baby will not become addicted. If your baby needs pain medications and sedatives for a long time, physical dependence may occur. Physical dependence is not the same as addiction—addiction is a psychological problem. Because of this physical dependence, medication doses will be decreased slowly to prevent possible withdrawal symptoms that can occur if the medicine is stopped suddenly. Nurses and doctors will watch your baby carefully for signs of medication withdrawal. Comfort measures such as holding, rocking, and giving a pacifier can be helpful when doses of pain and sedation medications are being decreased.

What about when infants have to have shots or other medical procedures?

Procedures are invasive medical treatments. They may be mildly invasive, such as stitches, shots, and blood draws, or they may be more invasive, as in surgery. Medical procedures can cause your baby emotional distress as well as varying degrees of pain.

As all parents know, children receive a series of vaccine shots in infancy. One study found that using easy behavioral interventions helps babies feel less pain and stress with these shots [4]. The University of Michigan researchers simply had parents distract and engage their infants with sucking (breastfeeding, finger or pacifier), rubbing, rocking, singing, or getting them to look at an interesting object while the staff person got the shot ready. If possible, the parent continued the distraction while the staff person gave the shot. EMLA and giving glucose (a sugar solution) together were found to alleviate immunization pain in a study of three-month-old infants [5] Another study found that when parents held their babies, let them suck and gave them a sweet solution during a series or four injections, the babies cried less than without holding and sucking. Both parents and nurses found this strategy easy to use [6]. For venipuncture (blood draw), a study found that glucose on a pacifier was more effective at reducing infants’ pain than EMLA cream [7]. Breastfeeding, or a pacifier dipped in sugar water is also helpful in decreasing the amount of time spent crying after medical procedures [8]. A review of 17 different studies on giving sucrose with or without sucking on a bottle or pacifier concluded that sucrose is safe and effective for reducing pain from minor medical procedures; however, the dose, use in preemies, and repeated use need more study [9].

So the bottom line of all these studies is: during shots, blood draws, and other minor medical procedures:

Hold your baby, if you can, during the procedure and/or afterward.
Breastfeed or give sugar water in a bottle or on a pacifier during and/or afterward.
Use other forms of distraction, such as sucking, rubbing, rocking, singing, shaking a rattle, showing a toy, etc. before, during and afterward.
Ask your doctor about applying EMLA cream before scheduled shots and blood draws.

For more information on infants and medical procedures, including more serious procedures, such as surgery:

Should my baby boy have any anesthesia during his circumcision?
Yes! Newborns who are circumcised without an anesthetic experience true pain. We can tell they have pain because they have the signs: increased blood pressure, increased heart rate, decreased oxygen in the blood, and a surge of stress hormones. Circumcision is surgery on a very sensitive part of the body. Research suggests that boys who were circumcised without any anesthetic experience more trauma (pain and fear) with each of their many routine childhood vaccines. Fortunately, many local pain-killers are now used for circumcision. Ask your doctor about EMLA cream, dorsal penile nerve block (DPNB), and the subcutaneous ring block. A review of the research concludes that DPNB is the most effective treatment for preventing circumcision pain [10]. In addition, while letting your baby suck on sugar water on a pacifier or your fingertip is not enough pain control on its own, combined with effective treatment, it can help comfort him and may enhance pain control. Acetaminophen (Tylenol) can help dull the pain, but is not enough by itself for surgical pain. The American Academy of Pediatrics' (AAP) 1999 policy statement says that pain treatment is safe and effective and should always be provided during infant circumcision. In addition, the AAP states that the benefits of circumcision are not great enough to recommend circumcision as a routine procedure.

There’s no excuse for circumcision pain!
The AAP's circumcision policy
News release about the AAP’s policy
Watch a video about the AAP’s circumcision policy.

What is teething?

Teething is when your baby’s gums get inflamed and sensitive as new teeth grow, pushing their way against and through the gums. When your baby is teething, they will probably drool a lot, be fussy, and have red, swollen gums. Although there is actually no scientific evidence to support the connection between teething and low-grade fever or mild diarrhea, most parents and many health practitioners believe in this connection. Babies may get a rash on their faces because of all the drool.

How can I help my baby with teething pain?

Here are some ways to help your baby be more comfortable:

You can hold, comfort and carry your baby.
Try distraction—for example, rock, pat, or sing or talk to your baby, let them suck on your finger or a pacifier, or show them interesting objects.
Rub your baby’s sore gums with your finger.
Make sure your baby has plenty of safe toys and other objects like a washcloth to chew on. You can wet a corner of a clean washcloth and freeze it. This makes a great and soothing chew-toy for your baby. Don’t let your baby chew on chokable objects.
Ask your doctor about using acetaminophen (Tylenol) or ibuprofen (Advil or Motrin) for your baby’s teething pain.
You could try using the homeopathic remedy Chamomilla (chamomile) for teething accompanied by diarrhea. Homeopathic Chamomilla may help with diarrhea related to cutting teeth [11] [12]. Ask your baby’s doctor about trying Chamomilla if your baby is restless, whining, or irritable and clinging. However, if your baby has more than 6-8 watery stools (poopy diapers) in a day, or has vomiting with diarrhea, call your baby’s doctor right away.

Not all teething treatments work or are safe. Here are some to avoid:

Honey on a pacifier can cause botulism in infants. Don’t give honey to babies under one year old.
Over-the-counter numbing gels quickly wash off the gums with saliva, and the numb feeling can be unpleasant for babies. These gels also numb the throat muscles, and can cause swallowing problems and gagging.
Frozen teething rings can hurt babies’ gums.

For more information on teething:

Are there any books about infants and pain?

Crying Baby: Resource List—recommended books about soothing crying babies
Soothing your Child’s Pain: From Teething and Tummy Aches to Acute Illnesses and Injuries—How to Understand the Causes and Ease the Hurt, by Kenneth Gorfinkle.

Where can I find other resources related to pain and babies?

Your Child: Colic
Prevention and Management of Pain and Stress in the Neonate is a policy statement from the American Academy of Pediatrics that discusses how doctors can make new babies more comfortable.
The Assessment and Management of Acute Pain in Infants, Children and Adolescents is a policy statement from the American Academy of Pediatrics.
Fussy babies—here is a wealth of suggestions for comforting fussy babies (who are often uncomfortable babies).
Pediatric pain links includes self-help links for parents.
The Mayday Pain Project site features Internet resources and pain news.
Pediatric Pain Management is written for staff education, but will be useful for parents, as well. It includes information about assessing pain in infants and children, classifying types of pain, treating pain with medication and non-drug approaches, and addiction and dependence to pain medications.