ORIGINAL ARTICLE

Efficacy of swaddling and heel warming on pain response to heel

stick in neonates: a randomised control trial
Shao-Hui Shu, Ying-Li Lee, Mark Hayter and Ruey-Hsia Wang

Aims and objectives. To determine the efficacy of swaddling and heel warming
on pain response in neonates following heel stick. What does this paper contribute
Background. Swaddling has been suggested to reduce pain response in neonates to the wider global clinical
during heel stick. Heel warming is also often performed for drawing blood easily community?
before heel stick. However, the efficacy of both on pain response is unclear. • Both swaddling and heel warm-
Design. A randomised controlled study was used. ing decreased the pain response
Methods. Twenty-five neonates were randomly assigned to each of the control, of neonates during heel stick.
swaddling and heel-warming groups. Heart rate, oxygen saturation Neonatal
• Heel warming resulted in a lower
pain response than did
Infant Pain Scale and duration of crying were used to assess pain reactivity and swaddling for neonates,
pain recovery. A greater heart rate and Neonatal Infant Pain Scale increase, or particularly in terms of pain
oxygen saturation decrease, indicated higher pain reactivity. A longer duration of recovery.
heart rate and oxygen saturation changes after heel stick back to baseline indi- • Heel warming could become a
routine practice to decrease the
cated a longer pain recovery.
pain response of neonates during
Results. The decrease in oxygen saturation in swaddling group was significantly heel stick.
greater than that in heel-warming group. The increase in the Neonatal Infant Pain
Scale in control group was significantly higher than that in swaddling group. The
heart rate recovery time in control group and swaddling group was significantly
longer than that in heel-warming group. The oxygen saturation recovery time in
control group was significantly longer than that in heel-warming group. The dura-
tion of crying in control group was significantly longer than those in swaddling
group and heel-warming group.
Conclusion. Both swaddling and heel warming decreased the pain response of
neonates during heel stick. Heel warming resulted in a lower pain response than
did swaddling for neonates, particularly in terms of pain recovery.
Relevance to clinical practice. Heel warming could become a routine practice to
decrease the pain response of neonates during heel stick.

Key words: heel stick, heel warming, neonates, pain responses, swaddling

Accepted for publication: 5 December 2013

Authors: Shao-Hui Shu, RN, MSN, Doctoral Student, College of
Nursing, Kaohsiung Medical University, Taiwan and Lecturer, Fac-
ulty of Nursing, Tzu Chi College of Technology, Taiwan; Ying-Li
Lee, RN, MSN, Specialist of Nursing Department, Chi Mei Medi-
cal Center, Taiwan; Mark Hayter, PhD, RN, MMed. Sci, BA Cert.
Ed, FAAN, Head of Department of Nursing and Professor, Faculty
of Health and Social care, University of Hull, UK; Ruey-
Hsia
Wang, PhD, RN, Professor, College of Nursing, Kaohsiung Medi-
cal University, Kaohsiung, Taiwan.
Correspondence: Ruey-Hsia Wang, Professor, College of Nursing,
Kaohsiung Medical University, No. 100, Shih-Chuan 1st Rd.,
Kaohsiung, Taiwan, 80708, China. Telephone: +0886-7-3121101
ext. 2641.
E-mail: wrhsia@kmu.edu.tw

© 2014 John Wiley & Sons Ltd

Journal of Clinical Nursing, 23, 3107–3114, doi: 10.1111/jocn.12549 3107
S-H Shu et al.

Introduction recovery. Reactivity indicates a change of reaction, from

the baseline to postpain stimulus, whereas pain recovery
Neonates admitted to neonatal intensive care units are fre-
indicates the duration of recovery from the time of reaction
quently subjected to various procedures that can be pain-
to a painful stimulus back to the baseline level (Stevens
ful (Anand 2007). Both term and preterm neonates who
et al. 2007b). Variations in the heart rate (HR) and oxygen
experienced frequent or excessive painful stimuli, such as
saturation (SaO2) are the key physiological indicators used to
venipuncture and heel stick, have reduced cognitive and
assess pain responses. A pain stimulus results in increas- ing
motor development as toddlers (Grunau et al. 2009).
HR and decreasing SaO 2 (Hummel & van Dijk 2006). A
Thus, minimising the pain inflicted on neonates is crucial
greater HR increase and SaO 2 decrease indicate higher pain
for neonatal care. However, current neonatal pain man-
reactivity and a higher pain response (Stevens et al. 2007a,
agement in clinical settings is insufficient (Fitzgerald &
Gibbins et al. 2008). Moreover, a longer recovery time for
Walker 2008, dos Santos et al. 2012). This paper presents
HR and SaO2 from postpain stimuli back to the baseline
findings from a study to investigate the efficacy of swad-
indicates a higher pain response (Huang et al. 2004).
dling and heel warming on pain response in neonates
Heel stick is a routine blood sampling procedure in neo-
undergoing one of the most frequent procedures – heel
natal care units. Lancing and squeezing the heel are the
sticks.
main pain stimuli for neonates during heel stick.
Swaddling is securely wrapping neonates in a blanket to
Background prevent their limbs from moving around excessively (Pillai
Riddell et al. 2011). Generally, swaddling can help the
According to anatomical, physiological and behavioural
self-regulating ability of neonates (Blom et al. 2009),
studies, neonates can perceive pain (Grunau et al. 2006,
promoting calm and sleep (Franco et al. 2005) and
Simons & Tibboel 2006). Because neonates cannot ver-
soothing crying (van Sleuwen et al. 2007). There are
bally express themselves, behavioural and physiological
evidences that swaddling effectively decreases pain
indicators are used to measure their pain responses.
reactivity (Prasopkittikun & Tilokskulchai 2003, Morrow
Facial expressions (Ahola Kohut et al. 2012) and body
et al. 2010). Swaddling can also shorten the pain recovery
movements (Holsti & Grunau 2007) are considered to be
time (Fearon et al. 1997, Huang et al. 2004) after heel
behavioural indicators of pain among neonates. Facial
stick. Swaddling is supported as a useful interven- tion for
expressions include brow bulge, eye squeeze, nasolabial
reducing the pain response in neonates undergoing the heel
furrow and mouth movement (Ahola Kohut et al. 2012).
stick procedure. However, more studies are needed to
Body movements involve movements of arms, hands, legs
confirm the findings.
and feet (Holsti & Grunau 2007). Crying is also a signif-
When environmental temperatures are warmer than the
icant behavioural indicator of pain among neonates (Cho´liz
human body, the skin surface temperature increases (Leh-
et al. 2012). A previous study has supported the notion
mann 1990). Applying a heat pack to the skin increases the
that strong and long-lasting crying indicated a strong pain
skin surface temperature, and the increase in the skin sur-
response among neonates (Cho´liz et al. 2012).
face temperature causes proximal blood vessels to dilate
The neonatal infant pain scale (NIPS) is frequently used
(Greenberg 1972). Vasodilatation may reduce the
to measure pain responses in neonates, by assessing facial
squeezing pressure on the heel of neonates, because
expression, crying, breathing patterns, arm movements, leg
drawing blood becomes easy, which may mitigate the pain
movements and state of arousal (Lawrence et al. 1993). A
perception in neonates when the heel stick is performed.
higher NIPS score represents a stronger pain response in
Heel warming using heat packs has been applied as a
neonates (Taddio et al. 2011). The NIPS provides a reliable
routine practice before heel stick in some neonatal care
way to assess the pain response in neonates (Duhn & Med-
units. Nevertheless, the effects of heel warming on the pain
ves 2004). Many studies have used the NIPS as a pain
responses in neo- nates have not been examined before.
assessment tool for neonates (Liu et al. 2010, Morrow
et al. 2010, Yilmaz & Arikan 2011).
A pain response can be interpreted in three phases: base- Aim
line, reactivity and recovery (Stevens et al. 2007b). A pain
The purpose of this study was to examine the efficacy of
response can be evaluated by pain reactivity and pain
swaddling and heel warming for reducing pain in neonates
undergoing heel stick procedures.

© 2014 John Wiley & Sons Ltd

310 Journal of Clinical Nursing, 23, 3107–
8 3114
Methods Participants

Design We used convenience sampling to recruit neonates pre-

This study used a randomised controlled design and was
conducted from July 2009–December 2010 in a district hos-
pital in Taiwan. Neonates were randomly assigned to swad-
dling (Group S), heel-warming (Group HW) or control
(Group C) groups. Before performing the heel stick, the
HR, SaO2 and NIPS of the neonates were measured (base-
line I). Then, participants were treated according to their
assigned groups. To understand the homogeneous of the
pain response among groups after intervention but before
heel stick, the HR, SaO 2 and NIPS were measured again to
assess the pain reactivity of the three groups (baseline II).
Then, for each participant, the heel was squeezed and
pierced, and the blood was collected. The HR, SaO 2, NIPS
and crying duration of each participant were measured
immediately after heel stick (post-test). The flow of recruit-
ment, intervention and measurement is shown in Fig. 1.
pared for the heel stick procedure from the neonatal
observation room of the hospital. Neonates included in
the study were born at a gestational age between 31–
41 weeks, younger than 30 days, had Apgar scores >7
and were not diagnosed with congenital anomalies or
intraventricular haemorrhages classified Grade II or above.
They had not been on respirators, sedatives or undergone
operations. Neonates who cried because of discomfort
from stools or hunger during the intervention, or who
were discharged before finishing the intervention, were
excluded.
Because of the difficulty of recruitment, 27 participants
were assigned to Group C, 27 to Group S and 28 to Group
HW during an 18-month study period. The final number of
participants was 25 for each group. Retention rates were
92·6%, 92·6% and 89·3% for Group C, Group S and
Group HW, respectively.

Assessed for eligibility

n = 82

Group C (n = 27) Group S (n = 27) Group HW (n = 27)

Lost to follow-up Discharged = 2 Lost to follow-up Discharged = 1 Lost to follow-up Discharged = 1

Baseline I: HR, SaO2, NIPS Baseline I: HR, SaO2, NIPS Baseline I: HR, SaO2, NIPS

None intervention for 30 min Swaddling for 30 min until post-test None intervention for 25 min

Lost to follow-up Crying because of stool = 1 Lost to follow-up

Crying because of hungry = 2

Heel-warming for 5 min

Baseline II: HR, SaO2, NIPS Baseline II: HR, SaO2, NIPS Baseline II: HR, SaO2, NIPS

Heel stick Heel stick Heel stick

Figure 1 Flow of recruitment, intervention Post-test Post-test Post-test

and measurement (Group C, control group; HR, SaO2, NIPS, Crying HR, SaO2, NIPS, Crying HR, SaO2, NIPS, Crying
Group S, swaddling group; Group HW, heel-
warming group; HR, heart rate; SaO2, oxygen Analyzed (n = 25) Analyzed (n = 25) Analyzed (n = 25)
saturation; NIPS, neonatal infant pain scale).

Interventions
All experiments were conducted between 6:00–7:00 AM
because it was the quietest time in the ward. All partici-
pants were fed and their diapers changed one hour before
the interventions.
Swaddling group: Neonates were placed face up on a 90-
cm2 blanket. The arms of the neonates were placed close to
their torso with both hands clasped. The upper and lower
ends of the wrap were kept open, and the upper rim was
aligned with the shoulder of the neonate. The horizontal
ends of the wrap were folded in opposite directions to
cover the torso. The tightness of the swaddle was examined
to ensure a comfortable fit, without restraining limb move-
ments. The remaining portion of the wrap was then folded
into the back and secured by the body weight of the neo-
nate. An appropriate space was retained at the foot of the
wrap before folding it upward to the front, completing the
swaddle. The lower end of the swaddle was unfolded to
perform the heel stick and enable blood collection. After
heel stick, the foot of the neonate was wrapped again. The
swaddling intervention was performed for 30 minutes and
continued until post-test, following the method of Huang
et al. (2004).
Heel-warming group: According to Lehmann (1990),
superficial heat between 40–45 °C increases the blood flow.
The effects of heat on skin temperature increased rapidly
during the first four minutes (Greenberg 1972). We put
water at 40 °C in a thermal bag and applied the thermal
bag against the puncture point for five minutes. Heel stick
was performed immediately after removing the thermal
bag.
Control group: Participants in the control group were
placed in a supine position while lying inside a crib and left
without intervention for 30 minutes before performing heel
stick.
Measurements
Personal characteristics: Personal characteristics included
gender, delivery method (vaginal or caesarean), emergency
treatment at birth (NaHCO 3 or 10% glucose), gestational
age, birth weight, postnatal age (hours after birth) and Ap-
gar scores at one and five minutes, collected from the medi-
cal records of the participant. The personal characteristics
of the participants were collected in their first day of admis-
sion in the neonatal observation room.
Neonatal infant pain scale: The NIPS was used to mea-
sure pain reactivity, assessing facial expression (0 = relaxed
muscles, 1 = grimacing), crying (0 = no cry, 1 = whimper,
2 = vigorous cry), breathing patterns (0 = relaxed, 1 =
changes in breathing), arm movements (0 = relaxed/
restrained, 1 = flexed/extended), leg movement (0 = relaxed/
restrained, 1 = flexed/extended) and state of arousal
(0 = sleeping/awake, 1 = fussy) (Lawrence et al. 1993). The
total score ranged from 0–7, with higher scores indicating
higher pain reactivity. The inter-rater reliability coefficient
of the NIPS was >0·85, and the Cronbach’s alpha score of
the NIPS was 0·91 (Taddio et al. 2011).
Duration of crying: A stopwatch was used to record the
duration (second) from the first cry immediately after heel
stick to the moment crying stopped. A longer crying dura-
tion indicated a longer pain recovery.
HR and SaO2: Electrocardiography (ECG) was used to
continuously measure HR and SaO 2. Disposable ECG leads
and pulse oximetry probes were placed on the bodies of the
neonates. Changes in the HR, SaO2 and NIPS between
baseline I and baseline II were used to assess the pain reac-
tivity before heel stick. Changes in the HR, SaO 2 and NIPS
between baseline II and post-test were used to assess the
pain reactivity after heel stick. A greater increase in HR or
NIPS, or decrease in SaO 2, indicated higher pain reactivity.
The duration of the recovery time of HR and SaO 2 from post-
test return to baseline II level was calculated as pain recovery.
A longer duration indicated a longer pain recov- ery. A higher
pain reactivity or longer pain recovery time indicated a higher
pain response.
Ethical considerations
This study was approved by the ethics committee of the
hospital in which it was conducted. The objectives and
experimental procedures were explained to the parents of
the neonates. The parents were informed that they had the
right to withdraw their child from this study at any time
without any adverse effects on care. Signed informed con-
sent was obtained from all parents before including their
neonates in the study.
Data analysis
Data analysis was conducted using the statistical package
SPSS for Windows, version 17.0 (SPSS Inc., Chicago, IL,
USA). Chi-square test was used to compare differences
between the personal characteristics of the three groups. One-
way ANOVA with Fisher’s least significant difference (LSD) was
used to compare the differences between groups. A
significance level of p < 0·05 was used in this study.
 Results
Distribution of demographic data among participants
No significant differences in gender, delivery method, emer-
gency treatment at birth, gestational age, birth weight, age
and Apgar score at one and five minutes were observed
between the groups (Table 1), indicating that the three
groups were homogeneous.
Pain response differences between the control group and
two experimental groups before heel stick
No significant differences were found between the three
groups regarding the increase in the HR and NIPS and the
decrease in SaO2 between baselines I and II (Table 2), indi-
cating that the intervention did not influence the pain
response of the three groups before heel stick.
Pain response differences between the control group and
two experimental groups after heel stick
Pain reactivity after heel stick: The increase in HR did not
exhibit significant differences between the groups after
heel stick (Table 2). The decrease in SaO2 and the
increase in the NIPS significantly differed between the
three groups. The LSD post hoc test indicated that the
decrease in SaO2 after heel stick found in Group S was greater
than that of Group HW. This indicated that the pain
reactivity of Group S was significantly higher than
that of Group HW in terms of SaO 2. In addition, the
LSD post hoc test indicated that increase in the NIPS after
heel stick in Group C was significantly higher than that in
Group S, indicating that the pain response in Group C
was significantly higher than that in Group S in terms of
the NIPS.
Pain recovery after heel stick: Pain recovery in terms of
HR, SaO2 and crying time differed significantly between
the three groups (Table 2). In terms of HR, the LSD post
hoc test indicated that the recovery time after heel stick in
Group C and Group S was longer than that found in Group
HW. This indicated that, in terms of HR, the pain
responses in Group C and Group S were significantly higher
than that in Group HW. In terms of SaO 2, the LSD post
hoc test indicated that recovery time after heel stick in
Group C was longer than that in Group HW. This indi-
cated that, in terms of SaO2, the pain response of Group C
was significantly higher than that of Group HW. The LSD
post hoc test indicated that the duration of crying after heel
stick in Group C was longer than that in Group S and
Group HW, indicating that, in terms of crying time, the
pain response of Group C was significantly higher than that
of Group S and Group HW.
Discussion
In this study, we applied various strategies to improve inter-
nal validity. Participants were randomly assigned to groups.
Personal characteristics did not significantly differ between
the three groups. Furthermore, pain reactivity before heel

Table 1 Distribution of Demographic Data in Participants

n = 25 n = 25 n = 25
Group C Group S Group HW

Variables n (%) Mean (SD) n (%) Mean (SD) n (%) Mean (SD) v2/F p

Gender
Male 12 48·0 17 68·0 11 44·0 3·32 0·19
Female 13 52·0 8 32·0 14 56·0
Delivery method
Vaginal 15 60·0 19 76·0 16·0 64·0 1·56 0·46
Caesarean 10 40·0 6 24·0 9·0
36·0 Emergency treatment on birth
No 19 86·4 19 82·6 16 72·7 2·83 0·59
Yes 3 13·6 4 17·4 5 22·7
Gestation (day) 266·80 (15·93) 269·20 (10·86) 269·60 (10·43) 0·36 0·70
Birth weight (gm) 2976·60 (547·05) 3133·76 (469·90) 2987·52 (619·01) 0·64 0·53
Postnatal age (hour) 60·06 (43·26) 38·60 (27·56) 42·72 (59·59) 1·75
0·21 Apgar score at one minute 7·72 (0·54)
7·88 (0·33) 7·64 (1·04) 0·76 0·47 Apgar

score at five minutes 8·80 (0·50) 8·96 (0·20) 8·80 (0·58) 1·03
0·36
Group C, control group; Group S, swaddling group; Group HW, heel-warming group.
Table 2 Pain Response among the Control Group and Two Experiment Groups before and after Heel Stick

n = 25 n = 25 n = 25
Group C Group S Group HW
Variables Mean (SD) Mean (SD) Mean (SD) F p LSD

Pain reactivity before heel stick

Increasing HR (beat/min) 12·36 (15·90) 16·72 (14·84) 9·96 (7·13) 1·68 0·20
Decreasing SaO2 (%) 2·32 (2·19) 2·56 (2·33) 2·72 (2·88) 0·16 0·85
Increasing NIPS 1·24 (1·36) 1·32 (1·49) 1·52 (1·26) 0·28 0·76
Pain reactivity after heel stick
Increasing HR (beat/min) 21·48 (15·32) 23·04 (21·88) 15·52 (15·06) 1·26 0·29
Decreasing SaO2 (%) 3·12 (3·35) 4·64 (5·33) 1·28 (1·46) 5·09 0·01 S > HW
Increasing NIPS 4·64 (2·02) 3·00 (2·47) 3·40 (2·22) 3·64 0·03 C> S
Pain recovery after heel stick
HR (minutes) 6·76 (3·80) 7·44 (4·87) 3·72 (3·14) 6·13 0·03 C, S > HW
SaO2 (minutes) 2·12 (2·32) 1·08 (1·53) 0·52 (1·83) 4·50 0·02 C > HW
Crying (seconds) 113·68 (101·50) 30·20 (31·81) 16·92 (17·83) 17·74 <0·01 C > S, HW

Group C, control group; Group S, swaddling group; Group HW, heel-warming group; HR, heart rate; SaO 2, oxygen saturation; NIPS,
neonatal infant pain scale; LSD, Fisher’s least significant difference.

stick was not different between the three groups. The
influence of personal characteristics and interventions on
the pain response before heel stick can be excluded. The
intervention and data collection were performed by differ-
ent individuals. Hence, the expectation bias that may result
when the same individual performs the procedures and col-
lects data was minimised.
The results showed that the pain reactivity of the swad-
dling groups was significantly lower than that of the con-
trol group. This is consistent with the study of Morrow
et al. (2010), who reported that swaddled neonates exhib-
ited low pain reactivity in terms of the NIPS after heel
stick. The NIPS had more response for calming effect.
Swaddling had a calming effect (Franco et al. 2005). There-
fore, pain reactivity in terms of the NIPS in the swaddling
group was lower than that found in the control group. Heel
warming did not have a calming effect. Therefore, pain
reactivity in terms of the NIPS in the heel-warming group
did not significantly differ from that of the swaddling
group.
The decrease in SaO 2 has clinical significance for assess-
ing pain reactivity (Huang et al. 2004, Liaw et al. 2012).
We found that Group HW had significantly lower pain
reactivity in terms of SaO 2 than did Group S. Thus, heel
warming might result in lower pain reactivity than swad-
dling. Previous studies have considered HR as an indicator
of pain reactivity (Stevens et al. 2007a, Gibbins et al.
2008). However, we found that the HR increase did not
significantly differ between the three groups in this study.
This result was consistent with that reported by Huang
et al. (2004). Combining the results from the NIPS and
SaO2, we might conclude that both heel warming and
swaddling resulted in lower pain response than that of the
control group.
The crying duration of Group HW and Group S was less
than that of Group C. The pain recovery measured by
SaO2 in Group HW was significantly lower than that in
Group C. These results indicated that both heel warming
and swaddling can reduce the pain recovery time in neo-
nates. Previous studies have indicated that the HR recovery
time in swaddled neonates was considerably lower than
that of a control group (Huang et al. 2004). In this study,
we found that the HR recovery time in Group HW was sig-
nificantly lower than that observed in Group S and Group
C. Thus, heel warming might be more effective for reducing
pain response than swaddling is.
Based on previous studies, we swaddled neonates for
30 minutes (Huang et al. 2004) and warmed the heels of
neonates using a thermal bag at 40 °C (Lehmann 1990) for
five minutes (Greenberg 1972). Although the reducing
effects of swaddling and heel warming on pain response
were demonstrated in this study, the most appropriate tim-
ing, duration and temperature for heel warming and swad-
dling still needed to be determined.
Little has been published on the effect of heel warming
on the pain responses of neonates. Furthermore, few studies
have compared the efficacy of heel warming and swaddling
on the pain response in neonates. In this study, both heel
warming and swaddling resulted in a lower pain response
than that of the control group. Additionally, the pain
response of the heel-warming group was lower than that of
the swaddling group. The mechanisms for reducing pain
response by swaddling or heel warming are different.
Swaddling has a calming effect. Heel warming reduces the Relevance to clinical practice
perception of pain caused by squeezing during heel stick. A
The results of this randomised controlled trial provide evi-
more rigorous experimental design is required to be able to
dence that both swaddling and heel warming are effective
compare the cost-benefit between swaddling and heel
in reducing heel-stick-related pain of neonates. As a result,
warming on pain response.
swaddling and heel warming could be adopted in the neo-
natal intensive care environment.
Limitations of the study

Because of the difficulty to recruit participants, the small Disclosure

sample size of each group might have increased the likeli-
The authors have confirmed that all authors meet the IC-
hood of type 2 error. The post hoc power analysis
MJE criteria for authorship credit (www.icmje.org/ethi-
indicated that the power of increasing NIPS, increasing HR
cal_1author.html), as follows: (1) substantial contributions
and recovery time of SaO 2 were lower than 80%. Thus, for
to conception and design of, or acquisition of data or
more accurate results, future studies should recruit more
analysis and interpretation of data, (2) drafting the article
neonates from several hospitals.
or revising it critically for important intellectual content,
and (3) final approval of the version to be published.
Conclusion
Both swaddling and heel warming can reduce the pain Acknowledgements
response of neonates during the heel stick procedure. We
The authors thank the neonates who participated in the
found that heel warming resulted in a lower pain response
study and Professor Yi-Hsin Yang for statistical advice.
than did swaddling during heel stick in neonates, particu-
larly in terms of pain recovery. Heel warming could thus
become a routine practice to decrease the pain response of Conflict of interest
neonates during heel stick.
There is no conflict of interest.

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