Heel Stick Procedure Research Articles

Preterm infants exhibited less pain during a heel stick when they were played the same music their mothers listened to during pregnancy.

Playing music during painful procedures has shown inconsistent benefits for preterm infants. This study observed preterm infants during a heel stick procedure to assess whether listening to the music their mothers listened to during pregnancy had any impact on their pain and physiological and behavioural parameters. We randomly exposed 42 preterm infants, with a mean gestational age of 31.8 ± 2.79 weeks, to the music their mothers listened to during pregnancy, recorded lullabies and no music, before, during and after a heel stick. Pain responses were measured using the Neonatal Pain, Agitation and Sedation Scale (N-PASS), and physiological and behavioural responses were recorded by a nurse blinded to the intervention. N-PASS pain scores were lowest during mothers' music, with a mean of 1.40 (±1.28), compared to 2.33 (±1.64) for no music and 1.62 (±2.27) for the lullabies [F(3/121) = 4.86, p = 0.009]. Physiological parameters were not significantly different between the conditions. During the mothers' music, infants spent more time in a quiet alert state, with a significant decrease in their respiratory rates. The music mothers listened to during pregnancy was more beneficial for preterm infants, as it decreased pain and improved behavioural states during a heel stick.

Effect of early procedural pain experience on subsequent pain responses among premature infants

Background and objectivesPreterm newborns are exposed to repeated procedural pain during their NICU stay. Acute pain has negative short-term effects and may have adverse neurodevelopmental sequelae. Disagreement among researchers exists in the direction of pain responses. We aimed at evaluating the short-term effects of early procedural pain exposure on subsequent behavioral and physiological responses among preterm infants; and to define possible contributing factors. Patients and methodsA prospective study included 203 preterm newborns recruited from 2 community centers, excluding cases having conditions that may affect pain responses. They were categorized into: group I including cases who were exposed to painful procedures; and group II were not exposed. Pain response to heel-stick procedure was assessed by Neonatal Infant Pain Scale to measure behavioral response, and changes in heart rate and oxygen saturation to evaluate physiological responses. ResultsHistory of pain exposure and number of procedures were the only independent variables that predicted subsequent pain responses while other contextual factors had no significant impact. The behavioral pain responses were blunted in group I with lower pain scores during and after the heel-stick test, while physiological responses were exaggerated with a higher heart rate and oxygen saturation variability. ConclusionOn studying the physiological and behavioral responses to pain in the premature infants, it was found that prior pain exposure and the number of procedures predict dampened behavioral and exaggerated physiologic subsequent pain responses. Protocols for minimization of pain exposure and pain control need to be implemented to avoid infant distress and long-term neurodevelopmental sequelae.

A feasibility and efficacy randomised controlled trial of swaddling for controlling procedural pain in preterm infants.

This study aimed to investigate the feasibility and efficacy of swaddling to control procedural pain among preterm infants. Swaddling has been recommended for controlling neonatal pain. However, the feasibility for use is uncertain and insufficient evidence is available among preterm infants. A two-arm randomised controlled trial with repeated measures. The study was conducted in a 21-bed neonatal intensive care unit of a regional hospital in Hong Kong. Preterm infants who required heelstick procedure were eligible. Fifty-four preterm infants between 30-37 gestational weeks were randomly assigned to swaddling (n=27) and control (standard care, n=27) groups. Pain assessment was performed pre, during, immediate, two, four, six and eight minutes after heelstick procedure using the Premature Infant Pain Profile. The mean Premature Infant Pain Profile scores were significantly reduced in the intervention group compared to the control group during, immediate, two, four, and six minutes after the heelstick procedure. The mean changes of heart rate and oxygen saturation in the intervention group were significantly lower than that of the control group at all measured time points. Notably, the swaddled infants quickly resumed to the baseline level at two minutes whereas the control group reached the stable state at an extended period of six minutes. The findings show that swaddling is feasible and efficacious in controlling pain for heelstick procedure among preterm infants. No adverse effects were observed. This article presents the feasibility and efficacy of swaddling as a non-pharmacological and non-invasive intervention to relieve pain during the heelstick procedures among preterm infants. Swaddling can contribute to control minor procedural pain in neonates as one of the simple, safe, cost effective, humanistic and natural analgesia alternatives.

Combined non-pharmacological interventions for newborn pain relief in two degrees of pain procedures: A randomized clinical trial.

Non-pharmacological interventions are effective neonatal pain reduction strategies. We aimed to study the effects of non-nutritive sucking (NNS) and swaddling on infants' behavioural and physiological parameters during shallow or deep heel stick procedures. In this prospective, multi-centred, randomized controlled clinical trial, we enrolled 671 newborns. The infants undergoing shallow or deep heel stick procedures were randomized into four groups: oral sucrose (routine care, group S), oral sucrose combined with NNS (group NS), oral sucrose combined with swaddling (group SS) and oral sucrose combined with NNS and swaddling (group NSS). The behavioural responses were evaluated by the Revised Neonatal Facial Coding System and the physiological signals were monitored by electrocardiogram monitors. A significant synergistic analgesic effect was observed between the NS and SS groups in both the shallow (F=5.952, p=0.015) and deep heel stick (F=7.452, p=0.007) procedure. NSS group exhibited the lowest pain score. For the deep heel stick procedure, the NS group had a significantly lower increase in heart rate (HR)% and decrease in SPO2 % than the S group (F=17.540, p=0.000, F=10.472, p=0.001), while this difference was not observed in the shallow heel stick procedure. No difference was found between the S and SS groups, in terms of different physiological parameters. Non-nutritive sucking and swaddling had synergistic effects on pain relief when used with oral sucrose. For the deep heel stick procedure, oral sucrose combined with NNS and swaddling provided the best pain relief effect. For the shallow heel stick procedure, addition of NNS and swaddling did not improve the effects.

To evaluate and compare the efficacy of combined sucrose and non-nutritive sucking for analgesia in newborns undergoing minor painful procedure: a randomized controlled trial.

The objective of this study was to evaluate and compare the efficacy of combined sucrose and non-nutritive sucking (NNS) for analgesia in newborn infants undergoing heel-stick procedures. This randomized control trial was conducted in the neonatal intensive care unit of a tertiary care hospital over a period of 1 year. One hundred and eighty full-term neonates with birth weight >2200 g and age >24 h were randomized to one of four interventions administered 2 min before the procedure: 2 ml of 30% sucrose (group I, n=45) or NNS (group II, n=45) or both (group III, n=45) or none (group IV, n=45). Primary outcome was composite score based on Premature Infant Pain Profile (PIPP) score. Baseline variables were comparable among the groups. Median (interquartile range) PIPP score was 3 (2 to 4) in group III as compared with 7 (6.5 to 8) in group I, 9 (7 to 11) in group II and 13 (10.5 to 15) in group IV. Group III had significant decrease in the median PIPP score compared with other groups (P=0.000). Median PIPP score also decreased significantly with any intervention as compared with no intervention (P=0.000). Sucrose and/or NNS are effective in providing analgesia in full-term neonates undergoing heel-stick procedures, with the combined intervention being more effective compared with any single intervention.

Effect of repeated Kangaroo Mother Care on repeated procedural pain in preterm infants: A randomized controlled trial.

Preterm infants' repeated exposure to painful procedures may lead to negative consequences. Thus, non-pharmacological pain management is essential due to medication side effects. Kangaroo Mother Care, which aims at offering human care to neonates, has been established for the treatment of a single painful procedure, but the effectiveness of Kangaroo Mother Care across repeated painful procedures is unknown. To test the effectiveness of repeated Kangaroo Mother Care on repeated heel-stick pain in preterm neonates. Randomized controlled trial. Level III Neonatal Intensive Care Unit at a large teaching hospital in northeast China. Preterm infants (gestational age less than 37 weeks) (n=80) were recruited and randomly assigned using a random table format to either an incubator group (n=40) or Kangaroo Mother Care group (n=40). Pain assessments were carried out during four routine heel stick procedures. For the first heel stick, preterm infants in each group received no intervention (routinely stayed in incubator). During the next three heel sticks, the infants in Kangaroo Mother Care group received heel sticks during Kangaroo Mother Care, while infants in the incubator group received heel sticks in incubator. The procedure of each heel stick included 3 phases: baseline, blood collection and recovery. Crying, grimacing and heart rate in response to pain were evaluated at each phase across four heel sticks by three trained independent observers who were blinded to the purpose of the study. Data were analyzed by analysis of variance (ANOVA), with repeated measures at different evaluation phases of heel stick. 75 preterm infants completed the protocol. Between-group comparison revealed that preterm infants' heart rate was significantly lower, and the duration of crying and facial grimacing were both significantly shorter in the Kangaroo Mother Care group (n=38) than the incubator group (n=37) from the blood collection phase to recovery phase during repeated heel sticks. No significant within-group difference was found in heart rate between the baseline phase and recovery phase through repeated heel sticks for Kangaroo Mother Care group. In contrast, the incubator group experienced significant within group differences in heart rate between baseline and recovery through repeated heel sticks. The effect of repeated Kangaroo Mother Care analgesia remains stable in preterm infants over repeated painful procedures. Given the many invasive procedures that are part of clinical care in preterm infants and most mothers preferred to provide comfort for their infants during painful procedures, Kangaroo Mother Care may be a safe analgesic alternative in preterm infants in whom it is feasible.

The Effect of Kangaroo Care on Pain and Physiological Parameters in Preterm Infants on Heel-stick Procedure: A Randomized Controlled, Cross-over Study

Background: Due to the higher risk of  pain in preterm infants, pain management is important for such infants. The present study aimed to determine the effectiveness of kangaroo care on the severity of pain and physiological parameters after heel-stick in preterm infants. Materials and Methods: This was a prospective and randomized controlled cross-over study. Twenty preterm infants allocated into an intervention (30 minutes of kangaroo care before and throughout heel-stick) and a control condition (standard incubator care during heel-stick). The severity of pain and the physiological parameters (heart rate and oxygen saturation) were collected after the heel-stick procedure. Results: The pain mean scores in the intervention and control conditions were respectively 4.9 (SD=2.91) and 11.00 (SD=4.21) and a significant difference was found between the two conditions regarding the pain score 30 seconds after the heel-stick [t=5.33, p<0.001]. Moreover, a significant difference between the two conditions concerning the infants' heart rate (F=3.73, p<0.0001) and oxygen saturation (F=1.84, p<0.0001) was demonstrated during the three study periods. Conclusion: In order to relieve the preterm infants' pain and prevent quick acceleration and deceleration of heart rate and oxygen saturation in the intervention condition, the intervention is recommended to be done in a nursery.

Effect of non-nutritive sucking and leg massage on physiological and behavioral indicators of pain following heel blood sampling in term neonates

Background: Pain management is especially important for neonates who are not able to verbally express their pain. Non-pharmacological pain management method as an alternative to pharmacological pain medication has increased nowadays. Objectives: The purpose of this study was to test the effect of leg massage and non-nutritive sucking (NNS) on reducing the pain that neonates experience when undergoing the heel stick procedure for blood testing. Methods: This investigation was a random controlled clinical trial study on ninety neonates who were selected randomly among admitted neonates to NICU in Alavi hospital at Ardabil. The subjects were randomly classified in two case and one control groups. The neonates received leg massage (n=30), NNS (n=30), and no intervention (n=30) respectively. Measurements of HR and SaO2 were taken twice: once before and then again after intervention. Pain response was measured by the PIPP scale. Results: The study showed that the HR of the three groups significantly increased after heel stick compared to before heel stick. The change of SaO2 levels in NNS groups was lower than the control and massage groups. The change of PIPP scores in massage and NNS groups was lower than that of the control group; however, there was not statistically significant differences between NNS & massage groups(p=0.91) Conclusion: pain management and pain relief in the infant is an important issue in neonatal health care. It is suggested that the single or combined use of massage and a pacifier is effective in reducing pain responses in neonates undergoing heel stick.

Facilitated tucking on pain in pre-term newborns during neonatal intensive care: A single blinded randomized controlled cross-over pilot trial

To determine the effect of facilitated tucking (FT) on pain in preterm newborns during heel stick procedure done as a part of neonatal intensive care. This randomized controlled cross-over pilot study included 20 preterm newborns of both sexes between gestational ages (GA) of 28 and 36 weeks based upon the eligibility criteria. Pain was measured using Premature Infant Pain Profile (PIPP) following both heel stick with FT and without FT. The newborns had a lower PIPP score at 30 seconds (Mean, SD: 8.80, 3.82), 60 seconds (Mean, SD: 7.55, 3.28), 90 seconds (Mean, SD: 7.25, 3.06) and 120 seconds (Mean, SD: 6.65, 3.05) when heel stick was done with FT compared to the same procedure done without FT at 30 seconds (Mean, SD: 11.20, 3.44), 60 seconds (Mean, SD: 10.75, 3.24), 90 seconds (Mean, SD: 10.60, 3.22) and 120 seconds (Mean, SD: 10.50, 3.15). A (2 X 4) factorial ANOVA showed a statistically significant difference between these two procedures in all the time periods viz., 30 seconds (p=0.044), 60 seconds (p=0.004), 90 seconds (p=0.002) and 120 seconds (p< 0.0001) at 0.05 level in PIPP score and favoring FT. FT is an effective non-pharmacological pain management in preterm newborns during routine neonatal intensive care.

Effects of combined use of non-nutritive sucking, oral sucrose, and facilitated tucking on infant behavioural states across heel-stick procedures: A prospective, randomised controlled trial

BackgroundPain and stress agitate preterm infants, interrupting their sleep. Frequent high arousal states may affect infants’ brain development and illness recovery. Preserving infants’ sleep and relieving their pain during painful procedures are both important for their health. ObjectivesTo compare the effectiveness of different combinations of non-nutritive sucking (sucking), oral sucrose, and facilitated tucking (tucking) with routine care on infants’ sleep–wake states before, during, and after heel-stick procedures. DesignProspective, randomised controlled trial. SettingLevel III Neonatal Intensive Care Unit in Taipei. MethodA convenience sample of 110 infants (gestational age 26.4–37 weeks) needing heel sticks were randomly assigned to five combinations of non-pharmacological treatments: sucking–oral sucrose–tucking; sucking–oral sucrose; oral sucrose–tucking; sucking–tucking; and routine care. Infant states, measured by a state-coding scheme, included quiet sleep, active sleep, transition, quiet awake, active awake, and fussing or crying. All states were recorded at 1-min intervals during four phases: baseline, intervention, heel-stick procedures, and recovery. ResultsInfants receiving sucking–oral sucrose–tucking or sucking–oral sucrose experienced 52.8% (p=0.023) and 42.6% (p=0.063) more quiet-sleep occurrences than those receiving routine care after adjusting for phase, baseline states, non-treatment sucking during baseline and recovery, positioning, and infants’ characteristics. Infants receiving oral sucrose–tucking, sucking–oral sucrose, sucking–oral sucrose–tucking, and sucking–tucking experienced 77.3% (p<0.001), 72.1% (p=0.008), 51.5% (p=0.017), and 33.0% (p=0.105) fewer occurrences of fussing or crying, respectively, than those receiving routine care after adjusting for related factors. ConclusionsThe four treatment combinations differentially reduced infants’ high arousal across heel-stick procedures. The combined use of oral sucrose–tucking, sucking–oral sucrose, and sucking–oral sucrose–tucking more effectively reduced occurrences of infant fussing or crying than routine care. Treatment combinations of sucking–oral sucrose–tucking and sucking–oral sucrose also better facilitated infants’ sleep than routine care. To preserve infants’ sleep, clinicians should use combinations of non-nutritive sucking, oral sucrose, and facilitated tucking to reduce agitation during painful procedures.

Contextual factors associated with pain response of preterm infants to heel‐stick procedures

Evidence indicates that medical and demographic contextual factors (cFs) impact pain responses in preterm neonates, but the existing evidence is very heterogeneous. To explore the effect of cFs on pain responses to heel-stick procedures of preterm infants. This study was a secondary analysis of data collected during a randomized controlled trial examining pain response to non-pharmacological interventions across repeated heel sticks. Five heel sticks across the first 14 days of life were videotaped. Pain response was rated with the Bernese Pain Scale for Neonates (BPSN) by four raters blinded to the heel-stick phases (baseline, heel stick, recovery). Demographic and medical cFs were extracted from medical charts. Mixed single and multiple regression analyses were performed controlling for the intervention group, site and heel-stick phase. Apgar scores at 1 min were negatively associated with behavioural (p = 0.002) BPSN scores, while Apgar scores at 5 min after birth were positively associated with behavioural (p = 0.006) scores. Accumulated number of painful procedures (p = 0.002) and gender (p = 0.02) were positively associated with physiological scores while continuous positive airway pressure CPAP (p = 0.009) and mechanical ventilation (p = 0.005) were negatively associated. Higher exposure to painful procedures, male infants and having CPAP or mechanical ventilation were cFs associated with physiological response. The only variables significantly associated with behavioural BPSN scores were Apgar scores but these relationships were inconsistent.

Effects of facilitated swaddling for controlling procedural pain in premature neonates: a randomized controlled trial

Preterm neonates are exposed to multiple painful medical interventions in neonatal intensive care units (NICU) but pain assessment and control remains suboptimal. Facilitated swaddling, as a pain relief intervention, has been studied among full term and healthy infants, however little attention has been given to premature neonates. We investigated the effect of facilitated swaddling to control procedural pain among premature neonates. 54 premature neonates between 30–36 6/7 gestation age from NICU were randomly assigned to facilitated swaddling (N=27) and control (no intervention, N=27). Written informed consent was obtained from a parent. Assessment of pain was performed pre, during, immediate, 2, 4, 6, and 8 minutes after heelstick procedure using the Premature Infant Pain Profile (PIPP). The PIPP is a composite measure of seven indicators including heart rate (HR) and oxygen saturation (SaO2), three facial responses to pain, behavioral state and gestational age. It has demonstrated high level of reliability and validity. The results showed that the mean PIPP scores were significantly reduced in the intervention compared to the control group (during, immediate, 2, 4, and 6 minutes after heelstick procedure) (P=0.001). The mean HR and SaO2 in the intervention group were significantly lower than that of the control group at all measured time points (P<0.001). Notably, both HR and SaO2 of the swaddled neonates resumed to the baseline level at 2 minutes whereas the physiologic outcomes of the control group reached the stable state at an extended period of 6 to 8 minutes respectively. These results suggest that facilitated swaddling was effective in controlling procedural pain of heelstick among premature neonates. No adverse effects were observed. It has been suggested that the motor containment provides stimulation across the proprioceptive, thermal and tactile sensory systems that may reduce pain through gate control mechanisms.

Oral Sucrose and “Facilitated Tucking” for Repeated Pain Relief in Preterms: A Randomized Controlled Trial

To test the comparative effectiveness of 2 nonpharmacologic pain-relieving interventions administered alone or in combination across time for repeated heel sticks in preterm infants. A multicenter randomized controlled trial in 3 NICUs in Switzerland compared the effectiveness of oral sucrose, facilitated tucking (FT), and a combination of both interventions in preterm infants between 24 and 32 weeks of gestation. Data were collected during the first 14 days of their NICU stay. Three phases (baseline, heel stick, recovery) of 5 heel stick procedures were videotaped for each infant. Four independent experienced nurses blinded to the heel stick phase rated 1055 video sequences presented in random order by using the Bernese Pain Scale for Neonates, a validated pain tool. Seventy-one infants were included in the study. Interrater reliability was high for the total Bernese Pain Scale for Neonates score (Cronbach's α: 0.90-0.95). FT alone was significantly less effective in relieving repeated procedural pain (P < .002) than sucrose (0.2 mL/kg). FT in combination with sucrose seemed to have added value in the recovery phase with lower pain scores (P = .003) compared with both the single-treatment groups. There were no significant differences in pain responses across gestational ages. Sucrose with and without FT had pain-relieving effects even in preterm infants of <32 weeks of gestation having repeated pain exposures. These interventions remained effective during repeated heel sticks across time. FT was not as effective and cannot be recommended as a nonpharmacologic pain relief intervention for repeated pain exposure.

Non-nutritive sucking and facilitated tucking relieve preterm infant pain during heel-stick procedures: A prospective, randomised controlled crossover trial

BackgroundPreterm infants’ repeated exposure to painful procedures may contribute to negative consequences. Thus, improving preterm infants’ neurodevelopmental outcomes requires prioritising their pain management. ObjectivesTo compare the effectiveness of two non-pharmacological pain-relief strategies (non-nutritive sucking and facilitated tucking) with routine care on preterm infants’ pain, behavioural, and physiological responses before, during, and after heel-stick procedures. DesignProspective, randomised controlled crossover trial. SettingLevel III Neonatal Intensive Care Unit in Taipei. MethodThirty-four preterm infants (gestational age 29–37weeks) needing three procedural heel sticks were recruited by convenience sampling and randomly assigned to a sequence of three treatments (two pain-relief interventions and the control condition): (1) routine care, non-nutritive sucking, facilitated tucking, (2) non-nutritive sucking, facilitated tucking, routine care, and (3) facilitated tucking, routine care, non-nutritive sucking. Each treatment condition was performed on a different day to avoid any carry-over effect. Pain was measured by the Premature Infant Pain Profile (PIPP), infant behaviour by a behavioural coding scheme, and physiological signals by electrocardiogram monitors. All data were collected 3min without stimuli (baseline), during heel-stick procedures, and recovery. ResultsInfants receiving non-nutritive sucking and facilitated tucking had significantly lower mean (standard deviation) pain scores during heel-stick procedures (6.39 [3.35] and 7.15 [3.88], respectively) than those receiving routine care (9.52 [4.95]). Infants receiving non-nutritive sucking and facilitated tucking had significantly lower odds ratios (0.39, p=0.011 and 0.34, p=0.005, respectively) for pain (PIPP score≥6) than infants receiving routine care after adjusting for time, baseline pain scores, and infants’ characteristics. Similarly, infants receiving non-nutritive sucking and facilitated tucking had significantly lower odds ratios (0.23, p<0.001 and 0.28, p=0.03, respectively) for moderate-to-severe pain (PIPP score≥12) than infants receiving routine care. Infants receiving facilitated tucking had lower frequency ratios for stress-related behaviours, abnormal heart rates, and decreased oxygen saturation than infants receiving routine care. ConclusionsBoth non-nutritive sucking and facilitated tucking effectively reduced pain scores more than routine care during heel-stick procedures. Non-nutritive sucking reduced PIPP pain scores more effectively than facilitated tucking. However, facilitated tucking showed broader effects not only on relieving pain, but also on enhancing infants’ physiological and behavioural stability during heel-stick procedures.

Psychometric analysis of a Taiwan‐version pain assessment scale for preterm infants

To determine the inter-rater reliability, internal consistency, construct and concurrent validity and feasibility of the pain assessment scale for preterm infants. Repeated exposure to painful procedures has an adverse impact on preterm infants' health outcomes. Although many scales are available for assessing these infants' pain, only a few reliably and validly assess pain and no gold standard has been established in clinical practice. Instrument development and psychometric analysis. Preterm infants (n = 60) born 27·6-36·3 weeks gestational age were assessed for pain 3 minutes before (phase I), during (phase II), 3 minutes after (phase III) and the tenth minute after (phase IV) heel-stick procedures. Pain scores were independently coded from video recordings and observations by three trained nurses using our pain-assessment scale, premature infant pain profile and visual analogue scale. Scores on the pain assessment scale for preterm infants differed significantly across four phases of heel-stick procedures (F = 56·86, p < 0·0001). Internal consistency was 0·84 and inter-rater reliability was 0·88-0·93. Scores on our pain scale correlated well with scores on the premature infant pain profile (0·74-0·83) and visual analogue scale (0·72-0·81). The pain assessment scale for preterm infants integrates all possible pain indicators, with each item modified for clinicians' simple and easy pain measurement to potentially yield different information. Our scale is valid, reliable and feasible for preterm infants with gestational age > 27 weeks. Further examination of the scale's psychometrics is recommended with diverse samples of infants and different painful procedures. The pain assessment scale for preterm infants clearly defines item scoring and weighting, consistently discriminates different levels of pain and helps nurses to recognise infants' pain. Nurses can easily remember the definition of each item, allowing them to use our scale to evaluate preterm infants' pain at any time and to provide pain-relief interventions when needed.

Effects of Music on Physiological and Behavioral Indices of Acute Pain and Stress in Premature Infants: Clinical Trial and Literature Review

Infants in intensive care units often undergo medically necessary heel-stick procedures. Because the risks of administering analgesics and anesthetics are often thought to outweigh the benefits, there remain no proven means of ameliorating the pain and stress these infants suffer, particularly during procedures. This study examined the controlled use of recorded vocal music to attenuate physiological and behavioral responses to heel stick in 13 premature infants via an experimental design. In both instances, infants exposed to music and infants in the control group, heart rate, and respiration rate increased during the heel-stick procedure (P’s 1⁄4 .02) and nearly all infants cried. During a 10-minute recovery following the heel stick, heart rate, and crying significantly decreased in infants exposed to music (P 1⁄4 .02) but not in unexposed infants. Controlled music stimulation appears to be a safe and effective way to ameliorate pain and stress in premature infants following heel sticks. Keywords NICU music, infant, heart rate, pain, heel stick, premature

Randomized Crossover Trial of Kangaroo Care to Reduce Biobehavioral Pain Responses in Preterm Infants: A Pilot Study

Kangaroo care (KC), skin-to-skin contact between mother and infant, is a promising method for blunting pain responses. This crossover pilot tested KC effects on biobehavioral responses to heel stick in preterm infants (30-32 weeks' gestational age, 2-9 days old) measured by Premature Infant Pain Profile (PIPP) and salivary and serum cortisol. Mother-infant dyads were randomly assigned to KC heel stick (KCH) first or incubator heel stick (IH) first. Study 1 (80-min study, N = 18) tested the effect of 80 min of KC before and throughout the heel stick procedure versus incubator care. Study 2 (30-min study, N = 10) tested 30 min of KC before and throughout the heel stick versus incubator care. KCH and IH began during a premeasurement phase and continued through four data collection phases: baseline, heel warming, heel stick, and recovery. PIPP responses were measured every 30 s during data collection; salivary cortisol was measured at the end of baseline and recovery; and serum cortisol was measured during heel stick. Study 1 showed no differences between KCH and IH. Study 2 showed lower PIPP scores at four time points during recovery (p < .05 to p < .001), lower salivary cortisol at the end of recovery (p < .05), and lower serum cortisol during heel stick for the KCH condition (p < .05) as well as clinically lower PIPP scores in the KCH condition during heel stick. Thirty minutes of KC before and throughout the heel stick reduced biobehavioral responses to pain in preterm infants.

Prenatal treatment with glucocorticoids sensitizes the hpa axis response to stress among full-term infants.

The objective of this study was to determine the consequences for HPA axis functioning among healthy full-term newborns of prenatal treatment with the synthetic glucocorticoid (GC), betamethasone, which is the routine treatment for threatened preterm delivery. Ninety full-term infants were recruited into two study groups (30 betamethasone treated; 60 comparison group matched for GA at birth and sex). The cortisol and behavioral response to the painful stress of a heel-stick blood draw was assessed 24 hr after birth. Full-term infants exposed to prenatal betamethasone displayed a larger cortisol response to the heel-stick procedure, despite no differences in baseline levels. Further, within the recommended window of betamethasone administration (24-34 gestational weeks), infants exposed to betamethasone earlier in gestation displayed the largest cortisol response to the heel-stick. These data add to accumulating evidence that prenatal exposure to elevated GCs programs the development of the HPA axis.

1168 Contextual Factors Influencing Pain Response to Heel Stick Procedure in Preterm Infants: What Do We Know? a Systematic Review

Background: Major efforts to develop objective measurement tools for neonatal pain assessment have been made. However, the challenge of measuring pain in neonates remains, suggesting that contextual factors (CFs) might alter pain response in neonates. Although the role of CFs is increasingly discussed as crucial for pain assessment, they are not well described in the literature and barely considered in the clinical setting. Aim: To explore the impact of CFs on pain response in preterm infants. Method: Literature search was undertaken considering the period from 1990-2009. Studies reporting about the relation between one or more CFs and pain response in preterm infants during heel stick procedure were considered. Results: 23 studies were included. The studies varied highly related to the design, sample, analysis procedures, and examined variables. Six categories of CFs emerged: Age, pain exposure, health status, therapeutic interventions, behavioral status, and demographic factors, indicating that some of the CFs might have an effect on pain response in preterms. However, none of the CFs was consistently related to pain response as evidenced by contradictory findings. Inconsistency between behavioral and physiological pain response related to CFs further aggravates accurate conclusions. Conclusion: This review indicates a possible influence of some CFs on pain response. However, the results remain inconclusive, which is particularly due to the heterogeneity of the studies. CFs need further investigations in order to get more evidence regarding the magnitude of their effect on pain response. Further evidence has the potential to contribute to achieve another level of measurement of this complex phenomenon.

Prenatal maternal stress programs infant stress regulation

Prenatal exposure to inappropriate levels of glucocorticoids (GCs) and maternal stress are putative mechanisms for the fetal programming of later health outcomes. The current investigation examined the influence of prenatal maternal cortisol and maternal psychosocial stress on infant physiological and behavioral responses to stress. The study sample comprised 116 women and their full term infants. Maternal plasma cortisol and report of stress, anxiety and depression were assessed at 15, 19, 25, 31 and 36 + weeks' gestational age. Infant cortisol and behavioral responses to the painful stress of a heel-stick blood draw were evaluated at 24 hours after birth. The association between prenatal maternal measures and infant cortisol and behavioral stress responses was examined using hierarchical linear growth curve modeling. A larger infant cortisol response to the heel-stick procedure was associated with exposure to elevated concentrations of maternal cortisol during the late second and third trimesters. Additionally, a slower rate of behavioral recovery from the painful stress of a heel-stick blood draw was predicted by elevated levels of maternal cortisol early in pregnancy as well as prenatal maternal psychosocial stress throughout gestation. These associations could not be explained by mode of delivery, prenatal medical history, socioeconomic status or child race, sex or birth order. These data suggest that exposure to maternal cortisol and psychosocial stress exerts programming influences on the developing fetus with consequences for infant stress regulation.