Many misconceptions exist about pain and stress in infants born preterm. Healthcare workers commonly believe that infants born preterm do not perceive and/or experience pain.1,2 However, research supports that these infants not only feel pain but, when compared to infants born at term, have a heightened response.2,3 This heightened response is believed to be due to an imbalance of neurotransmitter activity, preventing the nervous system of the infant born preterm from suppressing incoming pain signals.4,5 A infant born preterm requires an increased amount of routine care and may need repeated medical procedures, which may cause a decreased pain threshold due to prolonged hypersensitivity.3,5,6 Therefore, nonnoxious stimuli such as routine handling and care may be perceived as painful and elicit stress responses.5
Stress responses in infants born preterm may be exhibited through different behaviors in different systems: autonomic, motor, and behavioral state.7,8 The autonomic system controls physiological responses such as heart rate (HR), oxygen saturation (Sao2), respiration rate, blood pressure, skin color, visceral signs, and involuntary motor patterns.1,3,7 Motor behaviors include posture, tone, and movement patterns, particularly those of the face.1,3,7 Facial expressions are considered to be the most consistent and convincing indicators of pain and stress in infants.1,9 Typical facial expressions of pain in infants include brow bulge, eye squeeze, nasolabial furrow, and wide open mouth.1,3,5,10 Behavioral states are indicative of an infant’s arousal level.1 An infant may be in one of seven behavioral states: deep sleep, light sleep, drowsy, awake/alert, awake/fussy, awake/aroused and crying, or unavailable. According to synactive theory, the autonomic, motor, and state systems are continually interacting with each other.11 If there is stress or instability in one system, this may produce instability in others.11 In order to adequately determine stress responses in an infant born preterm, all the systems must be assessed in combination with each other.1,11
One method of assessing these systems in combination is the Premature Infant Pain Profile (PIPP). This assessment tool recognizes pain as a complex, multidimensional phenomenon among infants born preterm.12,13 The PIPP measures physiological activity, behavioral state, and facial activity. These three factors are believed to best reflect painful experiences of infants born preterm.1,12,13 When the PIPP is used, objective data show that pain does exist in infants born preterm; therefore, finding ways to manage this pain is imperative.
Pain management in infants can be classified as either pharmacological or nonpharmacological. When managing severe pain, pharmacological agents such as narcotics or opiates may be used.1,14 However, the use of medication is not without risk. Some risks include respiratory depression, sedation, nausea, seizures, and physiological dependence.1,3 These adverse effects may be one reason why there is an undertreatment of the pain phenomenon in infants born preterm.15
Nonpharmacological measures can be beneficial in managing minor pain and/or stress as a substitution or adjunct to medication. Two existing methods that have been found beneficial are considered to be methods of comforting. They include nonnutritive sucking and facilitated tucking.1,3,15 Facilitated tucking is defined as the gentle positioning of an infant’s arms and legs in a flexed, midline position close to the infant’s body while the infant is in either a side-lying, supine, or prone position.14 Facilitated tucking has been shown to be an effective comfort measure for infants born preterm.14–16 Specifically, lower mean HRs and shorter crying times were observed after painful procedures.14
An infant born preterm is unable to maintain physiological flexion independently. Positioning the infant in a tucked position allows the infant to gain a sense of postural security, promotes normal motor development, and aids in energy conservation.5 Facilitated tucking aids an infant’s ability to use his or her own self-regulatory skills, such as hands to mouth and grasping or holding, so the infant can better cope with minor pain and stress.7
Nurses and other neonatal intensive care unit (NICU) providers should be knowledgeable about pain assessment in newborns as well as how infants born preterm and infants born at term respond differently to pain.14,17 When increased stress in infants is not recognized and left untreated, there may be lifelong consequences.15,17,18 Some of these consequences include cognitive disorders, learning disorders, poor motor performance, psychosocial disorders, impulsive behavior, and lack of control in social situations.1,17–19 These long-term effects may be prevented by reducing the amount of stress in the NICU environment through individualized and developmentally supportive care.3,16
Facilitated tucking is only one of the many essential elements of developmentally supportive care that neonatal nurses and care providers use to manage stress in infants born preterm.14 The philosophy of developmentally supportive care promotes a relationship-based environment in which the goal is to support each infant to be as stable, well-organized, and competent as possible.16 Developmentally supportive care is family centered and collaborative. Care is individualized, organized, and paced in relationship to infant behaviors.3,16,20
The majority of previous studies have measured responses in infants born preterm during painful procedures such as heel sticks and circumcision.2,5,6,9,10,14 There are very few studies that show the effects of stress and the importance of facilitated tucking during routine care events with infants born preterm. The purpose of this study was to compare stress responses of infants born preterm during routine nursing assessments under two conditions. One condition incorporated a second caregiver supporting the infant in a facilitated tucked position, whereas the other condition did not. Routine assessments include such caregiving procedures as taking vital signs assessment, temperature checks, feedings, girth measurements, and diaper changes. The hypothesis for this study is that facilitated tucking will increase stability in infants born preterm during routine nursing assessments.
Twelve infants born preterm who were patients in the NICU at the time of testing were enrolled. A repeated-measures, random-sequencing design was used. The infants acted as their own controls to reduce the extraneous variables that exist among infants born preterm (eg, diagnosis, age, respiratory support, previous procedures). Inclusion criteria included infants born preterm who were patients in the NICU on the testing date, regardless of their diagnosis. Exclusion criteria included infants who were older than 34 weeks or younger than 24 weeks of age, corrected for prematurity on the testing date (corrected age).
The study received approval after institutional review for ethical and informed consent. Parents provided informed consent prior to participation.
Twelve infants born preterm (six male and six female) at 25 to 34 weeks corrected age (mean = 30.9 ± 2.5 weeks), with testing day weights ranging from 616 to 2105 g (mean = 1410 ± 473 g), participated in the study. Their gestational age at time of birth ranged from 24 to 32 weeks (mean = 28.8 ± 2.8 weeks). See Table 1 for infant demographics.
The study took place at St. Luke’s Hospital’s Helen G. Nassif Center for Women’s and Children’s Health in Cedar Rapids, IA. This facility is a level II regional, 22-bed, single-room-design, state-of-the-art NICU. The NICU design provided a subdued environment, in which all external stimuli to which infants born preterm may be exposed were kept to a minimum. The staff included two neonatalogists, a pediatrician, a nurse practitioner, nurses, a physical therapist (PT), an occupational therapist (OT), and a respiratory therapist. They all had completed level 1 Newborn Individualized Developmental Care and Assessment Program (NIDCAP) training. The NIDCAP provides a formal framework for implementing developmental care and represents the standard of practice at this NICU. In addition, one PT, one OT, and one nurse had achieved reliability in administration of the NIDCAP behavioral assessment.
The PIPP was used to measure differences in the infant’s autonomic, motor, and behavioral stability between the two testing conditions. This measurement tool is a seven-indicator pain measure that assesses an infant’s autonomic, motor, and state stability.1 Autonomic indicators include changes in HR and SaO2 that occur during the procedure. Motor indicators consist of three facial expressions (brow bulge, eye squeeze, and nasolabial furrow) noted during the assessment. The infant’s behavioral state prior to the time of testing and his or her corrected age are factored into the total score that the infant receives on the PIPP. An overall score is given based on the above indicators. See Appendices A and B for a copy of the PIPP and a description of scoring, respectively.
In a previous reliability study of the PIPP administered in a clinical setting, the intraclass correlation coefficient (ICC) was 0.93–0.96 for intertester reliability and 0.94–0.98 for intratester reliability.13 The PIPP was selected as an assessment tool because validity and reliability were already established and because it is relatively easy to administer and does not require extensive training.13 Prior to data collection, the investigators practiced scoring the PIPP by viewing a prerecorded videocassette of a infant born preterm during a procedure considered painful (eg, circumcision). After viewing the tape, each tester individually scored the infant’s response during the procedure using the PIPP, and all testers were able to achieve similar scores. The scores ranged from 11 to 12 for all trials with a mean score of 11.5.
Two of the testers were present on each of the testing dates over a three-month period. The PIPP was administered to all the infants born preterm in the NICU who met the inclusion and exclusion criteria and for whom parental consent was obtained. Each infant participated for one day. The PIPP was administered to each infant under each of the two conditions while undergoing routine episodes of care. During one episode of care, the nurse alone provided care to the infant. The infant was positioned in whatever manner the nurse thought was appropriate. During another episode of care, the nurse provided the care while the physical therapist supported the infant in a midline, tucked (flexed) position, in either a supine or side lying position (Fig. 1). The order of the conditions was randomly assigned for each infant. Variables that were held constant throughout the procedure to decrease the effect of extraneous variables on the outcome were as follows:
- Both episodes of care were provided on the same day.
- The nurse providing the care to each infant remained the same for 10 of the 12 infants.
- The physical therapist providing the postural support remained constant throughout all sessions.
- The entire segment of routine care was observed.
- Each day the same tester recorded all the objective data (HR and SaO2), while the other tester recorded only the infant’s facial changes.
Episodes of care were provided according to each infant’s care schedule, typically three to four hours apart. An entire segment of nursing care was provided, subject to each infant’s needs at the time. Care included such things as temperature checks, auscultation, blood pressure checks, diaper changes, and initiation of nasogastric tube feedings. Typical episodes of care lasted five to 10 minutes.
At the beginning of the care episode, two testers went to the bedside. One observer recorded the postconceptual age of the infant on the day of testing, the baseline behavioral state, HR, and SaO2 level of the infant on the PIPP score form. In one episode of care, the nurse then came to the bedside. In the other episode of care, the nurse and the physical therapist came to the bedside. When the physical therapist was involved in the episode of care, the infant was first brought into a midline, tucked position. The nurse proceeded to provide the infant with the needed care. Starting the moment that the nurse began to provide care, data were recorded at five-second intervals. Data collection was divided among the testers. One tester observed the infant’s facial responses necessary to score the PIPP. The other tester recorded the objective values of HR and SaO2 from the infant’s monitor (ALIGENT M1097-A02). A total score for the PIPP was calculated for each infant during both testing situations.
Level of significance was set at 0.05 prior to the start of this study. Means and standard deviations (SD) were calculated for infant demographics. The mean and the standard error (SE) of the PIPP score were determined for both caregiving situations. A paired t test was used to determine whether a difference existed between the two caregiving situations. MYSTAT for Windows (Course Technologies, Inc., Cambridge, MA) software was used to compute the statistical results.
Descriptive statistics of the infant demographics are displayed in Table 1. Table 2 identifies each infant’s PIPP score for both of the caregiving positions. Nine of the 12 infants received a lower score when a facilitated tucked position was used during routine nursing care. One infant received the same PIPP score under both conditions, while the remaining two infants’ PIPP scores were higher with facilitated tucking. As demonstrated in Figure 2, a significant difference existed between the two testing positions as measured by the PIPP (p = 0.013). The infants had a mean PIPP score of 8.5 (SE = 0.8) when in a facilitated, tucked position during routine care versus a mean PIPP score of 11.3 (SE = 0.7) without facilitated tucking.
The results from this preliminary investigation indicate that by incorporating facilitated tucking into routine care events, the stress levels of infants born preterm are significantly reduced. Infants born preterm have a decreased ability to maintain physiological flexion during stressful events; therefore, they are unable to be in a position that would aid them in self-comforting strategies. A facilitated tucked position allowed the infants in this study to better maintain stability in their autonomic, motor, and state systems, demonstrated by significantly lower PIPP scores.
Two infants, infants 5 and 8, had higher PIPP scores during facilitated tucking. The higher PIPP scores may be related to the infants’ medical conditions. Both infants 5 and 8 were very sick and had increased irritability. Infant 5 had increased pulmonary secretions during the trial incorporating facilitated tucking. Infant 8 was exposed to cocaine throughout pregnancy, demonstrated poor state control, and had to be awakened for routine care activities during the trial incorporating facilitated tucking.
Numerous uncontrollable events can occur in the NICU. On two occasions during this study, the nurses providing care for two of the infants did not remain consistent between trials. When infants 2 and 3 were awake and ready for care, the primary nurses were involved in emergent situations with other infants. Because the standard of practice at this NICU incorporates developmental care, attention to infants 2 and 3 was not delayed for the purpose of this study, and other nurses provided the care.
The research for this study was performed in a NICU that provided a nurturing atmosphere to both the infants and their families. The environment of this NICU was very quiet, calm, and dim. The nurses carefully timed care activities to occur when the infants were awake or in a more alert state. During the infant’s care, the nurse was mindful of the infant’s state; paced care according to the infant’s autonomic, motor, and state reactions; and used bumpers to assist with postural support. Some of the nurses also used facilitated tucking during care activities. The type of environment and caregiving activities previously mentioned are components of the developmentally supportive care philosophy. Differences in PIPP scores may have occurred had this research been conducted in a NICU where developmentally supportive care was not the standard of practice.
The results of this study may have also varied if a larger sample size was available, if the study was performed at several NICUs, or if the nurse providing the care remained consistent for all infants. Future studies should address these concerns. Due to the limited scope of this study, generalizations cannot be made to all NICUs. Each NICU is a unique environment with varying standards of practice. Further research is necessary to determine whether implementing facilitated tucking during routine care significantly reduces infants’ stress responses.
Nurses and other staff members in the NICU have the opportunity to provide a less stressful and more nurturing environment for infants born preterm. This involves reducing the negative stressors of the NICU environment through care that supports the infant to be as stable and well organized as possible. One means of reducing stress in infants born preterm is by incorporating a second caregiver to provide facilitated tucking during routine care events. The parent of the child, as the primary source of comfort and support, would be the ideal second caregiver to have at the bedside.
By incorporating facilitated tucking into routine care events, the stress levels of infants born preterm may be reduced. Facilitated tucking may help infants to better maintain stability in their autonomic, motor, and state systems.
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Keywords:© 2005 Lippincott Williams & Wilkins, Inc.
premature infant/physiology; premature infant/psychology; pain/prevention and control; pain measurement; adaptation/physiological; adaptation/psychological; physical therapy/methods