Complementary Therapies in Medicine 46 (2019) 103–108

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Complementary Therapies in Medicine

journal homepage: www.elsevier.com/locate/ctim

The effects of acupressure and foot massage on pain during heel lancing in T
neonates: A randomized controlled trial
⁎
Tuba Koç Özkan , Didem Şimşek Küçükkelepçe, Semiha Aydin Özkan
Adıyaman University School of Nursing, Midwifery Department, Altinsehir St., 02040 Adiyaman, Turkey

A R T I C LE I N FO A B S T R A C T

Keywords: Objective: To determine the effects of foot massage and acupressure on pain during heel lancing in neonates.
Acute pain Methods: A randomized controlled trial was performed in a university hospital in Turkey between February and
Venipuncture December 2018. The neonates were randomized into three groups as acupressure, massage, and control groups.
Acupressure Acupressure was applied to the neonates in the acupressure group, and massage was given to the neonates in the
Nursing
massage group for 2 min before the heel lancing procedure. Pain responses of the neonates in the groups was
Nonpharmacological methods
evaluated with the Neonatal Infant Pain Scale during and 1 min after the heel lancing procedure.
Results: The study was completed with 139 neonates including 46 neonates in the acupressure group, 47 neo-
nates in the foot massage group, and 46 neonates in the control group. There were statistically significant
differences between the acupressure, massage and control groups in terms of their mean NIPS scores during
(4.30 ± 2.25, 3.95 ± 2.63, 6.04 ± 1.26; respectively) and 1 min after the heel lancing procedure
(1.46 ± 1.46, 1.66 ± 1.66, 3.85 ± 1.37; respectively). There was a significant difference in NIPS scores be-
tween the intervention groups and the control groups (p = 0.001).
Conclusions: Acupressure and massage were effective in reducing pain in neonates during the heel lancing
procedure. However, there was no statistically significant difference between acupressure and massage.
Acupressure and massage techniques can be applied for procedural pain management in the newborn.

1. Introduction hands or special tools.14,15 As for acupressure, it is a method applied by

stimulating the acupuncture points using hands and fingers by applying
Pain is an experience that affects people of all ages negatively, pressure on the meridians in body.12,16 Both methods are reliable,
mentally, physically, and socially. The belief that neonates did not feel economical and easy to learn and apply. Review of the related literature
pain changed after the 1980s, and newborns have proven to feel indicates studies on the effectiveness of acupressure and foot massage
pain.1,2 Starting from birth until discharge, neonates are exposed to on reducing pain in neonates.2,17 However, no studies were found to
many interventions such as vitamin K and Hepatitis B vaccination. In have compared the effects of acupressure and foot massage on pain
addition, in our country heel lancing practice is performed before dis- during heel lancing in neonates. Hence, this study aimed to identify the
charge from hospital in order to identify a number of diseases such as effects of foot massage and acupressure on pain during heel lancing.
phenylketonuria, hypothyroidism and biotinidase deficiency.3,4 Neo-
nates experience pain during these practices which may prevent their 2. Methods
adaptability to the outer world and lead to stress and physiological
imbalance. Therefore, preventing and reducing pain in neonates is of 2.1. Design
great importance.5,6 A number of evidence-based non-pharmacological
methods are reported to be used for the acute pain experienced by the The study was conducted as a randomized controlled trial with the
neonates. Some of these methods include kangaroo care, oral sucrose,7,8 purpose of identifying the effects of acupressure and foot massage on
breast feeding9 and music therapy10,11 Acupressure and massage are pain during heel lancing in neonates.
also reported to reduce pain caused by the procedures such as heel
lancing.12–14
Massage is a systematic and scientific procedure applied by using

⁎
Corresponding author.
E-mail addresses: tkoc@adiyaman.edu.tr (T. Koç Özkan), dsimsek@adiyaman.edu.tr (D. Şimşek Küçükkelepçe), saydin@adiyaman.edu.tr (S. Aydin Özkan).

https://doi.org/10.1016/j.ctim.2019.08.004
Received 7 April 2019; Received in revised form 4 August 2019; Accepted 5 August 2019
Available online 06 August 2019
0965-2299/ © 2019 Published by Elsevier Ltd.
T. Koç Özkan, et al. Complementary Therapies in Medicine 46 (2019) 103–108

2.2. Setting assessment was performed by a researcher (Didem Şimşek

Küçükkelepçe-DŞK). Physiological measurements were recorded by
The study was conducted between February and December 2018 another researcher (Semiha Aydın Özkan-SAÖ). Duration of crying and
with neonates in the postpartum services of a university hospital in duration of procedure were recorded by another researcher (Tuba Koç
Turkey. Özkan-TKÖ).
The heel lancing procedure was performed by the same nurse at the
2.3. Sample first attempt and at the same heel lancing procedure room. The room
temperature was 22–24 °C. The light of the room was white fluorescent
The inclusion criteria were having 2500–4000 g body weight and lamp during the heel lancing. Heel lancing was performed between
being term neonates, having APGAR score of over 7 five minutes after 07.00 a.m. and 09.00 a.m.
birth, having no health problems detected in the newborn examination
after birth, having received no painful interventions apart from 2.5.1. Procedures performed to the neonates in three groups 5 min before
Hepatitis B and vitamin K after birth, having received no acet- the heel lancing
aminophen or sucrose pacifier, being with the mother and being fed The researcher who conducted acupressure and massage practices
orally, having had breast milk within 30 min before heel lancing, and visited the mother-baby pairs in their rooms and asked the mothers to
having a clean diaper. choose one of the closed envelopes. All the procedures were explained,
Sample size was calculated based on the study conducted by Mir and verbal and written consent were taken from the mothers of the
et al18 (2018) that aimed to identify the effects of therapeutic touch and neonates to be included in the study. The information form that in-
heel warming on the pain during the heel stick procedure. Similar to the cluded the socio-demographic features of the neonates was filled in.
present study, the variables in that study included non-pharmacological The neonates were connected to the pulse oximeter monitor probe on
methods. Mir et al (2018) reported that NIPS pain scores after the the wrist. Their oxygen saturation and heart rate values were measured.
procedure were 2.8 ± 1.6 in the heel warming group and 4.4 ± 1.7 in Then neonates were taken to the procedure room to heel lancing by the
the control group. The study conducted with a total number of 78 nurse.
neonates, 23 in each group, was found to have α = 0.05 level, 89%
confidence interval, and d = 0.9692 effect size. In this regard, this 2.5.2. Procedures performed to the neonates in the interventions
study was conducted with 50 neonates in each group and 150 neonates (acupressure/massage) group 2 min before heel lancing
in total with a view to increasing the effect size of the study and taking Before the interventions were applied, the researcher washed her
data loss in the study process into consideration. Neonates were as- hands and kept them at body temperature. The interventions were
signed in the acupressure, massage, and control groups with the closed performed when the nurse was holding the neonate on her arm.
envelope method. Cards written “acupressure”, “massage” and “con- For two minutes, acupressure was performed in the acupressure
trol” on them were placed in closed envelopes, and the mothers were points (Kun Lun (UB60) and Taixi (K3). The acupuncture points Kun
asked to choose one of these envelopes. This way, 50 neonates were Lun (UB60) and Taixi (K3) are on the side of the ankle. These points are
assigned to the groups. A total number of 11 neonates were excluded effective in reducing pain.12,21 Each point was applied acupressure for
from the study due to some reasons (Fig. 1). Hence, the study was 60 s, and heel lancing was performed right after this procedure.
completed with 46 neonates in the acupressure group, 47 neonates in Neonates in the massage group were given foot massage for two
the foot massage group, and 46 neonates in the control group. minutes, and heel lancing was performed right after the massage.

2.4. Outcome measurements 2.5.3. Procedures performed to the neonates in all three groups during heel
lancing
An information form was prepared by the researchers using vari- The area to be applied heel lancing was cleaned using 70% alcohol
ables cited in previous investigations.15,18 The form included questions and left to dry for 30 s. Heel lancing was performed by an experienced
about birth weight, gestational age, postnatal age, gender and delivery nurse from the heel of the neonates with a 21-gauge needle. As soon as
method. the needle was pricked, the chronometer was started, and the time
Neonatal Infant Pain Scale (NIPS) was developed by Lawrence et al when the procedure ended was recorded. The other chronometer was
in 1993 in order to assess the pain responses of premature and term started once the neonate started to cry, and the time when s/he stopped
neonates. The scale consists of five behavioural sections and one phy- crying was recorded. Neonates’ pain during heel lancing was assessed;
siological section including facial expression, crying, breathing, arm oxygen saturation and heart rate values were recorded.
and leg movements, and alertness. Total scores range between 0 and 7.
Scores from 0 to 2 indicate mild to no pain, 3 to 4 indicates mild to 2.5.4. Practices performed to the neonates in all three groups 1 min after
moderate pain, and > 4 indicates severe pain. Higher scores indicate heel lancing
more severe pain. In the study of Lawrence et al, Cronbach's Alpha of Neonates’ pain was reassessed 1 min after heel lancing was finished.
NIPS was found 0.92.19 Adapted to Turkish by Akdovan, NIPS is used Oxygen saturation and heart rates were assessed again.
for the assessment of procedural pain of the premature and term neo-
nates.20 Cronbach's Alpha value was 0.87 in this study. 2.6. Data analysis
Pulse Oximeter Device calibrated Covidien Nellcor Pulse Oximeter
Monitor (Nellcor Puritan Bennett Inc.made in Pleasanton, Korea) was The collected data were evaluated using Statistical Package for the
used for the measurement of oxygen saturation and heart rate before, Social Sciences SPSS Statistics 22.0 (SPSS Inc., Chicago, IL, USA).
during and after heel lancing in all three groups. Descriptive characteristics of the neonates were analysed using de-
Duration of crying and heel lancing procedure were recorded with scriptive statistics (percentage, mean, standard deviation). When the
two Apple brand iPhone 6 plus telephone chronometers. data were evaluated according to the normality tests, it was found that
they showed normal distribution. Group differences of descriptive
2.5. Procedure characteristics were analysed using one-way ANOVA and Chi-square
test. Ancova test was performed to determine whether the variables
Prior to the study, the researcher received an acupressure certifi- (gender, gestational age) affect pain. Differences on pain between and
cate. Acupressure and foot massage were performed by the researcher within groups were analysed using one-way ANOVA and independent t-
(Tuba Koç Özkan-TKÖ) who had an acupressure certificate. NIPS pain test respectively. Differences in physiological parameters between and

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Fig. 1. CONSORT flow diagram.

within groups were analysed using one-way ANOVA and Repeated the acupressure group, 3.95 ± 2.63 in the massage group, and
Measures ANOVA respectively. Differences on the duration of crying 6.04 ± 1.26 in the control group. There was no statistically significant
and heel lancing procedure between the groups were analysed using between the acupressure and massage groups in terms of the NIPS
one-way ANOVA. Significance was assessed at the level of p < 0.05. scores (p > 0.05). The NIPS scores of the neonates in the acupressure
and massage groups were significantly lower than the control group
2.7. Ethical considerations (p < 0.05). (The mean difference (SE) and 95% confidence interval
(CI) of the mean difference between groups = control-acupressure:
Ethical approval was received from Adiyaman University Ethical 1.73 ± 0.38 and 0.98–2.49; control-massage: 2.08 ± 0.42 and
Committee (2018/1–5). The aim of the study was explained to the 1.23–2.93; acupressure-massage: 0.34 ± 0.50 and 0.66–1.35)
mothers and written informed consent was obtained from each mother. (Table 2).
The study registered in Clinical Trial Registry (NCT03906552). NIPS pain mean scores 1 min after the heel lancing were
1.46 ± 1.46 in the acupressure group, 1.66 ± 1.66 in the massage
3. Results group, and 3.85 ± 1.37 in the control group. The NIPS scores of the
neonates in the acupressure and massage groups were significantly
The neonates’ birth weight, gestational and postnatal age, gender, lower than the control group (p < 0.05). (SE and CI = control-acu-
and mothers’ birth type displayed similar distributions between the pressure: 2.39 ± 0.29 and 1.80–2.97; control-massage: 2.18 ± 0.31
groups (p > 0.05) (Table 1). and 1.56–2.81; acupressure-massage: 0.20 ± 0.32 and 0.84-0.44)
When the effect of gender among the groups on pain during and (Table 2).
after heel lancing was evaluated by ANCOVA test, it was found that There was a significant decrease in the pain mean scores after heel
gender had no effect on pain (F = 0.154 p = 0.695; F = 0.195 lancing according to the order of the during the heel lancing procedures
p = 0.660; respectively). When the effect of gestational age among the within groups (p < 0.05) (Table 2).
groups on pain during and after heel lancing was evaluated by ANCOVA Oxygen saturation between the groups was found to be statistically
test, it was found that gestational age had no effect on pain (F = 0,060 significant during the heel lancing (p = 0.009) (SE and CI = control-
p = 0,806; F = 0.284 p = 0.595; respectively). acupressure: 1.63 ± 0.60 and 2.83-0.42; control-massage:
NIPS pain mean scores during the heel lancing were 4.30 ± 2.25 in 2.04 ± 0.69 and 3.41-0.66; acupressure-massage: 0.41 ± 0.75 and

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Table 1
The comparison of the descriptive characteristics of the neonates in the groups (N = 139).
Characteristics Acupressure Group n = 46 Massage Group n = 47 Control Group n = 46 Total Statistics

× ± SD × ± SD × ± SD × ± SD

Birth weight 3.3 ± 3.9 3.2 ± 4.4 3.3 ± 3.6 3.2 ± 4.0 F = 0.620
n % n % n % n % p = 0.540
Gestational age (weeks)
38 21 45.7 25 53.2 25 54.3 71 51.1 X2=5.731
39 19 41.3 10 21.3 14 30.4 43 30.9 p = 0.220
40 6 13.0 12 25.5 7 15.2 25 18.0
Postnatal age (day)
1 22 47.8 24 51.1 21 45.7 67 48.2 X2=0.277
2 24 52.2 23 48.9 25 54.3 72 51.8 p = 0.871
Gender
Male 27 37.0 20 27.4 26 35.6 73 52.5 X2=2.871
Female 19 28.8 27 40.9 20 30.3 66 47.5 p = 0.238
Delivery method
Vaginal 19 36.5 19 36.5 14 26.9 52 37.4 X2=1.436
Caesarean 27 31.0 28 32.2 32 36.8 87 62.6 p = 0.488

F:One-way Anova ANOVA.

X2:Chi Square test.

Table 2 value measured one minute after heel lancing was found to be at border
The comparison of the pain scores of neonates in the groups. line; although this difference was not statistically significant, it was
NIPS Pain Acupressure Massage Control Group Statistics
found to be clinically significant (p = 0.052) (SE and CI = control-
Scale Group n = 46 Group n = 47 n = 46 acupressure: 1.21 ± 0.51 and 2.23-0.19; control-massage:
× ± SD × ± SD × ± SD 0.97 ± 0.52 and 2.01-0.06; acupressure-massage: 0.24 ± 0.52 and
0.81–1.29) (Table 3). The heart rate values of the neonates in the
During the 4.30 ± 2.25 3.95 ± 2.63 6.04 ± 1.26* F = 12.728
massage group were significantly higher than the control group one
heel p = 0.001
lancing minute after the heel lancing procedure (SE and CI = control-acu-
1 minute after 1.46 ± 1.46 1.66 ± 1.66 3.85 ± 1.37* F = 36.050 pressure: 3.23 ± 2.22 and 2.23-0.19; control-massage: 8.49 ± 2.76
the heel p = 0.001 and 13.98-3.00; acupressure-massage: 5.25 ± 2.76 and 10.74-0.23).
lancing
(p < 0.05) (Table 3).
Statistics t = 13.977 t = 9.450 t = 10.130
p = 0.001 p = 0.001 p = 0.001
Duration of crying and heel lancing procedure of the neonates was
recorded during the heel lancing. Hence, the duration of crying was
F = One Way ANOVA. 79.32 ± 56.93 s in the acupressure group, 46.81 ± 40.88 s in the
t = independent t-test. massage group, and 106.33 ± 62.39 s in the control group. The
* Tukey test. duration of crying was significantly shorter in the massage group than
the acupressure and control group (p < 0.05) (SE and CI = control-
1.90-1.08). According to the oxygen saturation measurements per- acupressure: 27.00 ± 12.45 and 2.25–51.74; control-massage:
formed in three different times within groups, oxygen saturation was 59.51 ± 10.91 and 37.83–81.19; acupressure-massage:
lowest during the heel lancing procedure (Table 3). Oxygen saturation p 32.51 ± 10.26 and 12.13–52.89) (Table 4).

Table 3
The comparison of physiological parameters of the neonates in the groups.
Physiological parameters Acupressure Group n = 46 Massage Group n = 47 Control Group n = 46 Statistics
× ± SD × ± SD × ± SD

Oxygen saturation
Before the heel lancing 95.78 ± 2.36 96.48 ± 2.16 96.36 ± 2.31 F = 1.271
p = 0.284
During the heel lancing 92.60 ± 3.25 93.02 ± 3.96* 90.97 ± 2.53* F = 4.934
p = 0.009
After the heel lancing 95.30 ± 2.49 95.06 ± 2.60 94.08 ± 2.43 F = 3.028
p = 0.052
Statistics F = 16.285 F = 11.304 F = 101.759
p = 0.001 p = 0.001 p = 0.001
Heart rate
Before the heel lancing 134.82 ± 10.69 134.57 ± 11.47 130.69 ± 10.12 F = 2.128
P = 0.123
During the heel lancing 161.21 ± 15.74 159.23 ± 18.84 158.54 ± 15.86 F = 0.311
p = 0.733
*
After the heel lancing 144.06 ± 10.7 149.91 ± 15.47 140.82 ± 10.67* F = 5.460
p = 0.005
Statistics F = 79.282 F = 67.250 F = 100.894
p = 0.001 p = 0.001 p = 0.001

a = One way ANOVA.

b = Repeated Measures ANOVA.
* Tukey test.

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Table 4
The comparison of the duration of crying and heel lancing procedure of neonates in the groups.
Time (Second) Acupressure Group n = 46 Massage Group n = 47 Control Group n = 46 Statistics
× ± SD × ± SD × ± SD

Duration of crying 79.32 ± 56.93 46.81 ± 40.88* 106.33 ± 62.39 F = 14.123

p = 0.001
Duration of heel lancing 125.46 ± 59.50 82.09 ± 26.22* 151.91 ± 80.06 F = 16.419
p = 0.001

F = One Way ANOVA.

p < 0.05.
* Tukey test.

The duration of heel lancing procedure was 125.46 ± 59.50 s in was significantly different 1 min after the procedure; this difference was
the acupressure group, 82.09 ± 26.22 s in the massage group, and found to be between the massage and control groups. This finding
151.91 ± 80.06 s in the control group. The duration of heel lancing showed that neonates in the control group had more pain than the
procedure was significantly shorter in the massage group than the neonates in the massage group during the heel lancing procedure. In
acupressure and control group (p < 0.05) (SE and CI = control-acu- addition, oxygen saturation and heart rate values of the groups were
pressure: 26.45 ± 14.70 and 2.76–55.67; control-massage: found to reach the normal values rapidly after the procedure. This
69.82 ± 12.30 and 45.39–94.26; acupressure-massage: 43.37 ± 9.50 finding was considered to result from the short duration of the heel
and 24.50–62.24) (Table 4). lancing procedure and fast physiological adaptation.
Infants, who cannot communicate verbally, use crying for commu-
4. Discussion nication. Crying is accepted as an important behavioural indicator for
the assessment of pain in infants.5,27 Abbasoğlu et al,12 in their study
It is important to use non-pharmacological methods in order to that aimed to identify the effects of acupressure on pain during heel
decrease pain in procedures such as heel lancing.24 Abbasoğlu et al,12 in lancing in preterm neonates, found that duration of crying in the acu-
their study conducted with preterm neonates, reported that acupressure pressure group was statistically significantly shorter. This study also
applied to BL60 and K3 points before heel lancing decreased pain. found that acupressure and massage shortened the crying duration of
Ibrahim et al13 found that foot massage applied before heel lancing the neonates. This finding indicated that acupressure and massage had
decreased pain in preterm neonates. In their study conducted with effects on the crying duration in neonates who were applied heel lan-
neonates, Chen et al24 found that non-invasive acupuncture applied cing, and the crying duration was shorter in neonates who were applied
before heel lancing decreased pain. Zargham-Boroujeni, Elsagh & Mo- acupressure and massage. Shorter crying duration was an indicator of
hammadizadeh,5 in their study that aimed to identify the effects of the effects of acupressure and massage in decreasing pain.
massage and breastfeeding on response to venepuncture pain among Acupressure and massage stimulate serotonin release. Serotonin
neonates, found that massage applied before venepuncture reduced causes vasodilation through nitric oxide, and capillaries increase per-
pain. Pain in neonates who were applied acupressure and massage was meability.5,12 Abbasoğlu et al12 reported that the duration of heel
found to be statistically significantly lower. This case showed that lancing was statistically significantly shorter in neonates who were
acupressure and massage decreased pain, but there was no superiority applied acupressure. İbrahim et al,13 in their study that aimed to de-
of acupressure and massage to each other in terms of decreasing pain. termine the effects of foot massage on pain during heel lancing in
This finding indicated that efficiency of acupressure and massage in preterm neonates, found that the duration of heel lancing was statisti-
decreasing pain was similar to each other, which was considered to cally significant shorter in the foot massage group. This study found
result from the fact that both methods were effective in decreasing pain that heel lancing duration was shorter in the babies who were applied
through tactile ways. acupressure and massage. This finding indicated that acupressure and
Perception of pain in neonates is affected by factors such as birth massage shortened the duration of heel lancing. The reason for shorter
weight, gestational week, postnatal age, gender, and type of birth.22,23 heel lancing in the acupressure and massage group was considered to be
This study indicated no differences between the acupressure, massage related to the vasodilation enhanced by serotonin and the effect of
and control group neonates in terms of birth weight, gestational weeks, capillary permeability. The duration of heel lancing was statistically
postnatal age, gender, and type of birth. Similar features in all three significantly shorter in the neonates who were applied massage. This
groups indicated that neonates’ reaction to pain caused by heel lancing finding indicated that massage was more effective in increasing vaso-
would be similar. dilatation and capillary permeability in comparison to acupressure. As a
Physiological variables are the parameters that support pain as- result, it is possible to say that massage shortened the duration of heel
sessment5,25,26 Jain, Kumar & McMillan,1 in their study that identified lancing according to acupressure.
the effect of massage on the pain during heel lancing, found that there
were no significant differences between the groups of oxygen saturation 4.1. Strengths of the study
values before, during and after the procedure and that heart rate was
statistically significantly lower in the massage group. Chen et al,24 in One of the strongest aspects of this study is that it was designed as a
their study conducted with neonates in order to identify the effect of randomized controlled study. Another strong side is that it is the first
auricular non-invasive magnetic acupuncture on the pain during heel study that compared the effectiveness of acupressure and foot massage
lancing, found that there were no significant differences between the on pain caused by heel lancing. One more strong aspect is that heel
heart rate and oxygen saturation values before, during and after the lancing was performed for all the neonates in the same hours, in the
procedure. When the groups were evaluated within each other, sig- same room, and by the same nurse. Finally, acupressure was performed
nificant differences were detected in the oxygen saturation and heart by a researcher who was trained about this issue.
rate values before, during and 1 min after the procedure. This finding
indicated that neonates in all three groups felt pain due to heel lancing. 4.2. Limitations
In addition, the assessment between the groups showed that oxygen
saturation was significantly different during heel lancing, and heart rate The results of the study were limited by this study group population.

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5. Conclusions 9. Zhu J, Hong-Gu H, Zhou X, et al. Pain relief effect of breast feeding and music therapy
during heel lance for healthy-term neonates in China: a randomized controlled trial.
Midwifery. 2015;31(3):365–372.
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