Introduction

 Pain, as defined by the International Association for the Study of Pain (2001), is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”(1).

Newborn infants routinely undergo painful invasive procedures, even after uncomplicated birth. Evidence shows that neonates do feel pain and may even have increased sensitivity to pain and to its long term effects compared with older infants (2).

Neonates cannot speak and advocate for themselves when they experience pain, which makes

nurses face enormous challenges because self-report is the gold standard for pain measurement. It is critical that nurses are able to recognize a neonate’s pain using appropriate pain tools; that is the first step toward effective pain relief (3).

Studies showed that infants had a mean of 10 to 16 painful procedures per day during their early lives. Research has continued to demonstrate that neonates can detect, process, and respond to painful stimuli, and they may actually have a 30% to 50% lower pain threshold than adults. Excessive and prolonged unrelieved pain in the infant causes adverse physiologic effects in all major organ systems including brain structure, can be life-threatening, and can have long-term cumulative outcomes (3).

Repetitive and prolonged pain experiences interfere with normal growth and development during the infant’s hospitalization and have implications for permanent changes in long-term neurodevelopment (1).

Effective pain prevention and treatment have been recommended as the standard of care at neonates, yet both pharmacologic and no pharmacologic pain interventions are still underused. Pharmacological treatments are rarely used during procedures because of concerns about their effectiveness and potential adverse effects (central analgesics). Therefore, non pharmacological interventions are valuable alternatives. Non-pharmacological interventions that have been tested in neonates that have shown varying degrees of efficacy can be categorized into sensory stimulation (positioning or swaddling, vestibular action or rocking, aromatherapy, non-nutritive sucking, music), nutritive (oral sweet solutions) and maternal interventions (maternal odor and voice, breastfeeding, and skin-to-skin contact or Kangaroo Care) (2-4).

The use of aromatherapy in nursing care continues to be popular in many settings. Most of the nursing literature relates to the use of essential oils in low doses for massage or use of the oils as environmental fragrances (5).

Lavender has sedative, antispasmodic and anti colic properties. As a result of these properties, it is thought that that might be able to relieve the symptoms of pain. Two means of administering lavender oil are recommended—topically and by inhalation. In pediatrics, to be able to use essential oils safely, it is important to know about their toxic effects, as well as to know which are the most appropriate ways of applying them including frequency of application for infants and children (6).

Most commonly lavender is recommended for oral administration. However, it is also being employed in aromatherapy (inhalation of lavender), aromatherapy massage, dripping oil and bathing. Lavender also prescribed by some medieval physicians such as Ebn-e-sina and Razi for treatment of epilepsy and migraine attacks. Furthermore, lavender is considered beneficial in treatment of pain and tremor (7).

The aim of this study was to investigate the effects of lavender scent on pain from blood sampling in term neonates.

Methods and Materials

This was a quasi experimental study of clinical trial type that carried out on 80 term neonate that hospitalized in the neonatology ward in Hashemi Nezhad Hospital affiliated with Mashhad University of Medical Sciences, Iran from July to December 2011. They were allocated to two intervention (40 neonates) and control (40 neonates) groups.

Inclusion criteria included: gestational age over 37 weeks, Appearance, Pulse, Grimace, Activity, Respiration (APGAR) scores at five minutes greater than seven, non-use of tranquilizer or sedative and anticonvulsant drug during the last 24 hours by mother and neonate, need for venous blood sampling, stability in general and clinical status and lack of  Diabetes in the mother.

Also, if the baby was restless and unsettled before the blood sampling or if the first attempt for blood sampling was not successful, if the infants in the intervention group, after the orientation phase of the scent or during the familiar within scent up to blood sampling, was discharged, were excluded from the study.

Because it was probable for the control group to be exposed to the lavender scent spread from experiment groups (diffusion effect), sampling was done only for one group during each week, with groups being randomly selected; in other words, on the first day, the name of each group was written on a separate piece of paper, then was lottery. During each week, eligible cases were recognized and selected by convenience sampling only for one group, and groups were replaced respectively.

Demographic information based on questionnaires and profile infants filled. To assess pain in infants was used from pain behavioral tool in neonate DAN. The DAN scale is a behavioral scale developed to rate acute pain in term and preterm neonates. Scores range from 0 (no pain) to 10 (maximum pain). The scale is used to evaluate 3 items: facial expressions (calm to very pronounced, continuous from 0 to 4 score) , limb movements(calm or gentle movements to very pronounced, continuous from 0 to 3 score ), and vocal expression (no complaints to long-lasting crying, continuous howl from 0 to 3 score).  Credit of collection tools data were evaluated using content validity, the reliability and validity of this instrument has been confirmed by researcher in Iran (8).

Lavender essence was obtained from a pharmaceutical company Baryj Essence. Three drops of lavender essence 100% was dissolved in 30 cc glycerin solution. By the company doctor mentioned and physician neonatal specialty innocuous use of scent for newborn babies were confirmed.

In the intervention group, a sterile gauze pad (10 * 10 cm) moistened with ten drops of lavender solution was placed in bed 10 cm from the neonate’s head, vicinity of nose.

The next morning, the scented gauze was removed for familiarization duration of 8 hours. Blood sampling was done in the presence of the lavender scent. The average time of blood sampling in neonates was half to one hour after removal of the gas.

Venous blood sampling in both intervention and control groups were performed by a skilled person and for collecting blood from veins in the back of hand and the 21-gauge needle was used. Along with needling, scores of DAN scale by the one fixed and trained person observed, calculated and recorded. Duration of crying, in the first three minutes of blood sampling were also measured. Start and completion criteria cry was based on the first cry, which was the duration of audible crying from the beginning (after needle insertion) until the cessation of crying for five seconds.

 But in control group, data collection and blood sampling were performed in the same manner as described for the experimental groups but no scent was given to them.

In this study, Chi-square, Kolmogorov-Smirnov, Mann-Whitney and independent t-test was used for statistical analysis. The level of significance was considered to be p

Results

In this study, 80 infants 3- 13 days were enrolled that the mean age was in the intervention 5.47 ± 1.97 and in the control group 5.55 ± 2.44. Female were 57.5%, 42.5% were first child and 67.5% were natural childbirth.

Average rating of DAN score was in control group 5.97 ± 1.94 and in experimental group 81/1±47/4. Mann–Whitney test results showed a significant difference in pain scores in the two groups (P=0.001). Time of crying was in intervention group 61.4 ± 21.13 second and in control group 75.15 ±35.65. The crying time between groups was not significant difference (P = 0.12). Although the average crying time in intervention group was less than the control group.

Table 1:  The demographic characteristics of newborns in the intervention and control groups

Table 2: Comparison of mean and standard deviations of scores of DAN scale and time of crying in intervention and control groups

Discussion

The results of this study showed, lavender scent can reduce pain in neonates in intervention group, that this decrease in comparison with control group was statistically significant, but had no effect on the duration of crying in infants.

A similar study that measured lavender scent on pain in neonate doesn’t found. Our findings are consistent with the results of Sadat hosseini, Negarandeh, and Movahedi showed that stimulating the neonates with a familiar vanillin scent during the arterial puncture reduced the duration of crying compared with the other groups. Comparison of the physiologic parameters showed less variation in oxygen saturation level during arterial puncture in the familiar scent group. In this study, a familiar scent could reduce crying and oxygen consumption during arterial puncture (9).

However, Romantsik, Porter and Varend have shown exposure to an unfamiliar odor did not have a calming effect on full-term neonates (10).

Goubet, Rattaz, Pierrat, Bullinger and Lequien showed that infants who were presented with a familiar odor during venipuncture showed no significant increase in crying and grimacing during the procedure compared to baseline levels. By comparison, infants presented with an unfamiliar odor or with no odor either during the heel stick or the venipuncture had a significant increase in crying and grimacing (11).

Cetinkaya and Basbakkal concluded that the use of aromatherapy massage using lavender oil was found to be effective in reducing the symptoms of colic in term neonates (6).

Study of Burns, Zobbi,  Panzeri, Oskrochi and Regalia showed there was a significant reduction in Neonatal intensive care unit‎ (NICU) admission for infants of the aromatherapy group, of whom there were none compared with six (2%) of the controls; this study revealed that the use of aromatherapy during labour as a care option that could improve maternal and neonatal outcomes (12).

Conclusion

Since the management and control of pain in infants is one of the most important the goals and tasks of nurses, search and use of all possible methods for this purpose should be in mind. In the hope that one day to minimize of feel pain in newborns.

Conflict of interest: None

Acknowledgments

The authors express their gratitude to all of the nurses and mothers for their kind cooperation in this study and Mashhad University of  Medical Sciences who was sponsored.