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August
2007: VOLUME
4, NUMBER 12
Skin-To-Skin
Care: Focusing On the Maternal–Infant Dyad
In
This Issue...
The
effectiveness of Skin-To-Skin Care (SSC, aka Kangaroo Care) for infants
at risk is supported by strong research and advocated by respected organizations,
including the World Health Organization. Despite a growing body of evidence
detailing the benefits of this intervention, SSC has yet to be adopted
as standard practice within Neonatal Intensive Care Units (NICUs) across
the nation and the world.
In this issue, we review the
most recent literature related to the practice of SSC, including specific
research on maternal and infant outcomes as well as barriers to implementation.
It is hoped that this information will assist clinicians in evaluating
the readiness of their NICUs to implement SSC, allowing them to develop
plans that are responsive to the needs of patients, caregivers, and
families, and to select measures to use in monitoring implementation
progress. |
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Course
Directors
Edward
E. Lawson, MD
Professor
Department of Pediatrics
Division of Neonatology
The Johns Hopkins
University
School of Medicine
Christoph
U. Lehmann, MD
Assistant Professor
Department of Pediatrics
Division of Neonatology
The Johns Hopkins
University
School of Medicine
Lawrence
M. Nogee, MD
Associate Professor
Department of Pediatrics
Division of Neonatology
The Johns Hopkins
University
School of Medicine
Mary
Terhaar, DNSc, RN
Assistant Professor
Undergraduate Instruction
The Johns Hopkins
University
School of Nursing
Robert
J. Kopotic, MSN, RRT, FAARC
Director of Clinical
Programs
ConMed Corporation |
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GUEST
AUTHORS OF THE MONTH |
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Commentary
& Reviews:
Mary
Terhaar, DNSc, RN
Assistant
Professor
Undergraduate
Instruction
The Johns
Hopkins University
School
of Nursing |
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Reviews:
Karen
P. Starr, MS, CRNP
Neonatal
Nurse Practitioner
Greater
Baltimore Medical Center
Department
of Neonatology
Towson,
Maryland |
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Guest
Faculty Disclosure
Mary
Terhaar, DNSc, RN has indicated no financial relationship
with commercial supporters.
Karen
P. Starr, MS, CRNP has indicated no financial relationship
with commercial supporters.
Unlabeled/Unapproved Uses
The authors have indicated that there will be no reference
to unlabeled/unapproved uses of drugs or products in this presentation.
Program
Directors' Disclosures |
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At
the conclusion of this activity, participants should be able to:
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Describe
the influence of Kangaroo Care on both the neonate and the mother |
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Explain
the effects of Kangaroo Care on pain in the neonate |
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Discuss
common barriers to the implementation of Skin-to-Skin Care in Neonatal
Intensive Care Units |
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COMPLETE
THE
POST-TEST
Step
1.
Click on the appropriate link
below. This will take you to the post-test.
Step
2.
If you have participated in a
Johns Hopkins on-line course, login. Otherwise, please register.
Step
3.
Complete the post-test and course
evaluation.
Step
4.
Print out your certificate.
Respiratory Therapists
Visit
this page to confirm that your state will accept the CE Credits
gained through this program or click on the link below to go directly
to the post-test.
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The
separation of mother and infant, while often necessary for the survival
of the pre-term infant in the NICU, is unnatural and stressful for
parents and infants alike. Just as the neonatal team employs the most
advanced technology and pharmacology available to improve outcomes,
so too should they investigate available environmental improvement
and support strategies to minimize the impact of separation and maximize
mutually beneficial interaction between mother and infant (and father
and infant).
SSC is a practice that holds
much promise for neonates in the NICUs of developed countries as well
as in other care settings in developing countries. SSC has been shown
to enhance gas exchange,1 increase restive sleep time,2 improve
the quality of sleep,3 decrease birth-related fatigue,4 provide
pain relief for term infants during heel-stick procedures,5,6 conserve
energy,7 decrease time to full enteral feeds, reduce the
impact of separation, promote parental involvement and bonding, and
improve transition to home following discharge.8 Most importantly,
SSC has been shown to reduce overall morbidity and mortality among low-birthweight
infants and to promote adaptive development.
There is a saying: "The only person who likes change is an infant in
wet diapers!" SSC represents significant change for clinicians in the
NICU. Perhaps that is why SSC meets such resistance in practice; some
believe it to be substandard care, while others find it too time consuming,
too risky for a fragile neonate, or simply "fluff" in the context of
real medical care. Addressing each of these concerns requires a thoughtful,
evidence-based response, as well as a careful strategy to reduce risk.
With such forethought, SSC can be successfully added to the many varied
approaches we can use to individualize care, implementation of SSC can
proceed in a far greater number of institutions, and caregivers will
become more competent and confident in its application.
Offering opportunities for a
mother to positively interact with her child very early in life requires
support from accessible bedside clinicians who are committed to implementing
SSC and who need not be drawn away for other unit activities. Attending
to the concerns of those clinicians requires involved administrators
who have responsibility for both staffing and the environment in which
care is provided. These are the key elements essential to the success
of any SSC program and to improving the well-being of the neonates and
the families in our care.
References
| 1. |
Fohe
K, Droph S, Avenarius S. Skin
to skin contact improves gas exchange in premature infants. J
Perinatol. 2000;20:311-315. |
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| 2. |
Messmer
PR, Rodriguez S, Adams J, et al. Effect
of kangaroo care on sleep time for neonates. Pediatr Nursing. 1997;23:408-414. |
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| 3. |
Ludington-Hoe
SM, Johnson MW, Morgan K, et al. Neurophysiologic
assessment of neonatal sleep organization: Preliminary results of
a randomized, controlled trial of skin contact with preterm infants. Pediatrics. 2006;117:e909-e923. |
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| 4. |
Ludington-Hoe
SM, Anderson GC, Simpson S, Hollingshead A, Aegote LA, Rey H. Birth-related
fatigue in 34-36 week preterm neonates: rapid recovery with very
early kangaroo care. J Obstet Gynecol Neonatal Nurs. 1999;28:94-103. |
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| 5. |
Ludington-Hoe
SM, Hosseini R, Torowics DL. Skin
to skin contact (Kangaroo Care) analgesia for pre-term infant heel
stick. AACN Clin Issues. 2005;16:373-387. |
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| 6. |
Gray
I, Watt L, Blass EM. Skin
to skin contact is analgesic in healthy newborns. Pediatrics. 2000;(1)105. |
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| 7. |
Ludington
SM. Energy
conservation during skin-to-skin contact between premature infants
and their mothers. Heart Lung. 1990;19:445-451. |
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| 8. |
Feldman
R, Eidelman AI, Sirota L, Weller A. Comparison
of skin-to-skin (kangaroo) and traditional care: Parenting outcomes
and preterm development. Pediatrics. 2002;110:16-26. |
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STRESS,
MOOD, AND PAIN PROFILES OF MOTHERS AND INFANTS DYAD DURING KANGAROO
CARE AS MEASURED BY CORTISOL LEVELS |
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| Morelius
E, Theodorsson E, Nelson N. Salivary cortisol and mood
and pain profiles during skin-to-skin care for an unselected
group of mothers and infants in neonatal intensive care. Pediatrics. 2005:116:1105-1113. |
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This
2005 prospective study by Morelius et al investigated the relationship
between SSC and stress among 17 mother-infant dyads in the NICU of
The University Hospital in Linkoping, Sweden. Infants were between
25 and 32 weeks’ gestational age; free from congenital anomalies,
neurological deficit or intraventricular hemorrhage; minimally 2
days of age; and were entered into the study before their first SSC
experience. Stress was measured using salivary cortisol levels and
heart rate measures in both mothers and infants. The researchers
controlled for the established lack of diurnal cortisol rhythm in
infants by conducting SSC sessions at the same time each day. In
addition, Mood Scale (MS) and Visual Analog Scale (VAS) data were
collected from mothers, and Premature Infant Pain Profile (PIPP)
and Neonatal Infant Pain Scale (NIPS) data were collected from the
infants. Saliva samples and heart rate were obtained prior to, during,
and after the first and fourth skin-to-skin care episodes.
The researchers found
that maternal salivary cortisol levels decreased during both the
first and fourth SSC encounter. At the first encounter, salivary
levels during SSC were 27% lower than pre-SSC levels, and post-SSC
levels were 32% lower than the initial measurement. At the fourth
encounter, salivary levels during SSC were 20% lower than pre-SSC
levels, and post-SSC levels were 38% lower than the initial measurement.
No significant difference was found when comparing data from the
first and fourth encounter. Similarly, maternal heart rates were
highest prior to SSC, decreased during SSC, and reached their lowest
levels following each encounter.
VAS decreased both
during and after SSC encounters, indicating reduced stress (high
scores reflect high stress). Maternal mood as measured by the MS
increased during and after SSC encounters as well (increased MS scores
reflect elevated maternal mood). Reinforcing the validity of these
findings, the mothers self-reported decreased stress and improved
mood during the skin-to-skin experiences.
Infant cortisol levels
showed inconsistent response to SSC: 38% of the sample had increased
levels, 38% had decreased levels, and 23% remained unchanged. Changes
in infant cortisol levels during and following the first SSC encounter
did not reach statistical significance. Data from the fourth encounter
showed 36% of the infant cortisol levels decreased during SSC, while
64% increased. Median levels were highest following SSC and lowest
before the encounter.
Further, infant pain
was found to decrease
during SSC: the NIPS score was highest prior to SCC and decreased
both during (P=.005, Fr/Wi) and following the first SSC encounter
(P=.04, Fr/Wi). This finding held true for the fourth SSC encounter
as well, during which the decrease in the NIPS was significant at
P=.04 and P=.03, respectively.
PIPP state data indicated
that infants moved into deeper sleep states during and following
SSC. No difference in state was established in relation to the first
SSC encounter. However, following the fourth SSC encounter, infants
were more likely to be in light/active sleep with eyes closed and
some facial movements before SSC, and in quiet sleep with eyes closed
and no facial movements after.
The authors attributed
the finding that infants experienced both increases and decreases
in cortisol levels to the immaturity of the hypothalamic-pituitary-adrenal
system. While this assertion is consistent with other research, further
investigation of neonatal cortisol measurement is necessary.
Heart rate, cortisol,
mood, and visual analog data support a conclusion that mothers had
a positive experience with SSC. Further, decreased pain as measured
by the NIPS and PIPP in conjunction with decreased infant heart rate
may lead clinicians to believe infants experienced decreases in pain
during SSC. However, there was a loss of infant data to either sample
contamination or insufficient volume; therefore, the analysis has
little power (although the methods and instruments used can be replicated
with larger samples to assure sufficient power). For clinicians,
the inconsistent infant data support a need for sustained, careful
attention to the mother-infant dyad while both partners experience
skin-to-skin care during the NICU stay. For researchers, these data
indicate the need for further investigation. |
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PARENTING
OUTCOMES AND PRETERM INFANT DEVELOPMENT |
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| Feldman
R, Eidelman A, Sirota L, Weller A. Comparison of skin-to-skin
(kangaroo) and traditional care: Parenting outcomes and preterm
infant development. Pediatrics. 2002;110(1):16-26. |
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Feldman’s
group investigated the influence of Kangaroo Care on long-term infant
development and parent-infant relationships. Participants included 73
matched pairs of infants from 2 institutions. The first institution
incorporated Kangaroo Care as standard practice (treatment group), enrolling
infants between 31 and 33 weeks post-conceptual age whose mothers agreed
to participate in Kangaroo Care for at least 1 hour a day for 14 consecutive
days; the second maintained standard NICU practices to serve as control.
Total time engaged in Kangaroo Care was documented. At 37 weeks gestational
age, a 10-minute mother-infant NICU interaction was videotaped and scored
by blinded, trained observers using the Mother-Newborn Coding System.
Mothers completed the Beck Depression Inventory (BDI) and Neonatal Parent
Inventory (NPI) as measures of depressive symptoms and assumption of
the parental role. Home Observation for the Measurement of the Environment
(HOME) was completed by trained observers at 3 months corrected age,
at which time the mother and father independently completed the Infant
Characteristic Questionnaire (ICQ). The Bayley Scales of Infant Development
(Bayley-II) was completed at 6 months corrected age. At each measurement
point, mothers completed a self-report tool. Finally, all infants’ medical
risk was measured using the Clinical Risk Index for Babies (CRIB).
The investigators report that
mothers participating in Kangaroo Care demonstrated significant differences
in interactive behaviors, scoring higher for positive affect, touch,
and visual regard for their infants. They found, however, no difference
in vocalization. Infants participating in Kangaroo Care demonstrated
more alert-scanning episodes and less gaze aversion during dyad interaction.
Both mothers and infants showed a favorable treatment effect (Wilks’ F
[df = 6, 137] = 12.47; P < .001). Further, mothers participating
in Kangaroo Care reported less depressive symptoms on the BDI and perceived
their infants to be more "normal" on the NPI. Significant positive correlation
between depressive symptoms and infant medical risk as measured by the
CRIB score was also established (Wilks’ F [df = 2, 141] = 4.86;
P< .01).
The 3-month evaluation for families
participating in Kangaroo Care showed a more optimal home environment,
as reflected in higher HOME scores for both mothers (Wilks’ F [df =
7, 123] = 2.99; P< .01) and fathers (Wilks’ F [df = 7, 110]
= 2.45; P< .05) . Infant temperament at 3 months of age showed no
difference between groups. Cognitive function as measured using the
Bayley II MDI and PDI scales at 6 months demonstrated a significant
positive effect for infants participating in the Kangaroo Care group
(Wilks’ F [df = 2, 128] = 5.41; P< .01). Using post hoc
analysis, the authors reported greater differences among high-risk infants
between the treatment (mean 85.14; SD: 17.88) and control groups (mean
77.91; SD: 13.68), data which are significant at the level of (F [1,61]
= 6.27; P, .01).
These findings establish a direct
connection between Kangaroo Care and favorable long-term outcomes for
preterm infants (even those at greatest risk) as well as for their families.
Specifically, the findings establish a positive, direct relationship
between Kangaroo Care and cognitive function at 6 months, maternal perception
of the infant as normal, and both maternal and paternal home environment.
These findings also establish a significant inverse relationship with
self-reported maternal depression. The finding of significant positive
effects on co-morbidities among high-risk premature infants is a strong
argument in favor of implementing Kangaroo Care in the NICU, which can
be accomplished with attentive caregivers, willing parents, and a responsive
administration. |
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BARRIERS
TO KANGAROO CARE IN DEVELOPING COUNTRIES |
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| Charpak
N, Ruiz-Pelaez. Resistance to implementing Kangaroo Mother
Care in developing countries, and proposed solutions. Acta
Paediatr. 2006;95:529-534. |
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This
descriptive study by Charpak and Ruiz-Pelaez aimed to identify processes
and strategies to support implementation of Kangaroo Mother Care (KMC)
and to subsequently improve management of the program in 25 developing
countries. Forty-four teams were trained in Bogotá, Columbia to initiate
Kangaroo Mother Care, described as 3 phases: the first, called Kangaroo
Position, involved a protocol for continuous skin-to-skin contact and
continued until the pre-term infant could maintain thermal stability
(at about 37 weeks); the second, called Kangaroo Feeding, involved regular
breastfeeding or feeding of breast milk around the clock; the third,
called Kangaroo Discharge, involved sending the infant home with the
mother in the skin-to-skin position, to be continued through regular
follow-up visits until the infant regained birth weight and steadily
gained 15 g/kg/day.
Seventeen teams from 15 developing
countries successfully implemented KMC programs – a 50% implementation
success rate. The database for analysis was developed from on-site standardized
field observation and interviews, as well as from a questionnaire sent
to both the successful and the unsuccessful teams concerning the problems
encountered during implementation and the solutions developed. By identifying
the implementation barriers and understanding the circumstances and
motivations leading to those barriers, the researchers sought to present
solutions for the benefit of others implementing KMC.
Several themes were identified,
with caregivers expressing negative perceptions in relation to all phases
of KMC practice. Some perceived KMC as a “poor man’s alternative” to
proper neonatal care, specifically designed for developing countries;
they also resented the additional work burden placed on health care
providers due to the careful monitoring and data collection necessary
to assure the stability and safety of the neonate. In some instances,
respondents indicated that the skin-to-skin contact itself was inappropriate,
expressing discomfort in relation to placing the infant on the bare
chest, a perceived lack of privacy, difficulty maintaining thermal control,
and cultural differences related to diapering. Caregivers also perceived
the work of infant nutrition to be increased by the breastfeeding component
of KMC, expressing the concern that breast milk is less desirable than
formula feeding. Further, health care respondents responsible for discharge
perceived that follow-up care was inadequate to assure infant safety.
In a similar vein, mothers expressed resistance, both because of the
demands KMC placed on their time and because it restricted the fathers’ participation.
Although the findings are from
providers in developing countries, the themes Charpak and Ruiz-Pelaez
captured can be useful to health care providers implementing skin-to-skin
care programs in the NICUs across the globe because an understanding
of these obstacles can aid individual units, health care organizations,
and businesses to reevaluate the need for Kangaroo Mother Care, and
to anticipate potential challenges during the implementation process.
The authors offer strategies for colleagues considering similar programs,
including distribution of evidence to health care professionals, administrators,
and health care decision makers regarding pilot studies during early
implementation; site visits or consultations with providers who have
successfully implemented SSC; and family and testimonials to be shared
with professionals and families alike. They also advocate the consistent
use of appropriate privacy protections, education concerning newborn
thermal management, and cultural training for all involved in SSC. |
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TRANSMISSION
OF MYCOBACTERIUM TUBERCULOSIS FOLLOWING EXPOSURE TO KANGAROO CARE |
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| Heyns
L, Gie RP, Goussard P, Beyers N, Warren RM, Marais BJ. Nosocomial
transmission of Mycobacterium tuberculosis in kangaroo care units:
A risk in tuberculosis-endemic areas. Acta Pediatr. 2006;95:535-539. |
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In
many developing countries, Kangaroo Care is considered to be the standard
of care. While KMC Units have demonstrated improved outcomes in neonates
as well as significant reductions in health care costs, they are often
small, poorly ventilated rooms shared by 4-8 mother-preterm infant pairs.
Therefore, an endemic infectious agent such as Mycobacterium tuberculosis (M.
tuberculosis), as reported in South Africa, can pose a threat of
nosocomial transmission to infants, families, and clinicians. This 2006
case report by Heyns et al describes a single experience of nosocomial
transmission of M. tuberculosis linked to a source within the
Kangaroo Care Unit.
Following the admission of a
3-month old to the Pediatric Intensive Care Unit, the infant was diagnosed
with pulmonary tuberculosis and an investigation was undertaken to identify
the possible source. The infant had been born at 29 weeks’ gestational
age and spent 23 days between 2 Kangaroo Care Units. A combination of
risk factors, including untreated active tuberculosis-positive pregnant
women, a tuberculosis-endemic environment, and confined, poorly ventilated
area, presented the opportunity for nosocomial transmission to all individuals
within this setting. However, the mother of this infant was not tuberculosis-positive,
nor were any contacts following hospital discharge. The investigation
identified the only possible source as a contact with another mother
within the Kangaroo Care Unit who had exhibited a chronic cough and
illness. Through smear microscopy and subsequent restriction fragment
length polymorphism testing, this mother was identified as the source
case. Subsequent testing revealed that 4 of the 6 neonates that shared
the Kangaroo Care Unit environment with the source case developed tuberculosis
within a 6-month period.
Heyns’ report reminds all clinicians of the need to be hypervigilant
in proactively screening all parents, visitors, and healthcare workers
in contact with any healthcare setting to decrease the possibilities
of nosocomial transmission of any organism to any population. |
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THE
INFLUENCE OF SKIN-TO-SKIN CARE ON NEUROPHYSIOLOGIC DEVELOPMENT AND
SLEEP ORGANIZATION |
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| Ludington-Hoe
SM, Johnson MW, Morgan K, et al. Neurophysiologic assessment
of neonatal sleep organization: Preliminary results of a randomized,
controlled trial of skin contact with preterm infants. Pediatrics. 2006;117:e909-e923. |
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Using
EEG/polysomnography at 32 weeks’ postmenopausal age, Ludington et al
investigated the influence of SSC on sleep organization. Subjects were
28 weeks’ gestational age or greater at birth, had 5-minute Apgar scores
of at least 6, were free from congenital brain malformations, and weighed
at least 1000g at the time of testing. All were born to mothers free
of substances during pregnancy. Pre-test data collection began at the
end of the 9:00 AM feeding: mothers came to the unit, pumped their breasts,
got into hospital gowns, and were ready to hold infants before the subsequent
feeding. Quiescence, activity, and discontinuous sleep were scored visually
from the EEG data, with changes in respiratory ratio and rate also recorded.
The investigators found SSC significantly
and favorably affected 3 variables related to arousal and 2 related
to REM sleep, reducing both arousal while sleeping and percent of sleep
epochs with more than 1 REM. Findings of regression analysis indicated
that, as compared to the control group, arousal time was significantly
lower in the SSC group (BSSC = -7.35; P= .015), and REM counts
were significantly lower in the SSC group as well (BSSC =
-5.11; P= .013).
The authors note that currently
employed developmentally-appropriate practices tend to encourage staff
to provide negative stimulation – for example, emphasizing minimal handling
without making the necessary distinction between noxious handling and
the comforting that parents can provide. Current practices also do not
consistently reduce interruptions in sleep. The findings of this study
invite caregivers to resist interruptions in sleep, and to use SSC as
a method to promote quiet restive sleep as a means to healthy neurodevelopment. |
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THE
INFLUENCE OF SKIN-TO-SKIN CARE ON PAIN |
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| Ludington-Hoe
SM, Hosseini R, Torowics DL. Skin to skin contact (Kangaroo
Care) analgesia for pre-term infant heel stick. AACN
Clin Issues. 2005;16:373-387. |
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The
researchers identified heel sticks as a common painful procedure performed
on infants in the NICU, and then developed a research model to test
the effects of SSC on pain response to the heel-stick procedure. Baseline
heart rate, change in heart rate, time crying, and sleep state data
were collected to measure pain response. Cry was defined as audible
vocalization or hard cry detectable by voice-activated recorder. Length
of cry was measured using a stopwatch, and calculated as the sum of
the cry time from onset to cessation greater than 5 seconds.
These data were used to describe
pain in response to heel sticks performed either before or after 3-hour
episodes of skin-to-skin care on 24 preterm infants randomly assigned
to 1 of 2 treatment groups. Caregivers performed heel sticks on infants
in Group A during a 3-hour SSC session, while heel
sticks were performed on infants in Group B before 3
hours of SSC.
The investigators found that
infants in group A had shorter crying time elevation (F [1,32] = 5.20,
P = .01 ) and less heart rate elevation (F [1,32] = 3.54, P = .042 )
as compared to infants in Group B. In addition, researchers evaluated
the 2 groups of infants for sampling bias and identified none.
While the sample size in this
study is modest, it is sufficient to support a power of 0.8 and alpha
of 0.05 for a medium effect size. Given that infants have the physiological
capacity to experience pain from 20 weeks’ gestation, interventions
that can relieve that pain without compromising already fragile body
systems add great value to the options for care management. |
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