Abstract
Background
Premature newborns admitted to neonatal intensive care units (NICUs) undergo numerous painful interventions during care and treatment. The purpose of this study was to compare the effects of using sucrose and kangaroo mother care by on selected physiological variables and pain resulting from venipuncture in premature infants admitted to NICUs affiliated with Shiraz University of Medical Sciences.
Methods
This clinical trial included premature infants admitted to 2 NICUs. The sample size consisted of 66 neonates, with 22 newborns in each group. Randomization was performed using the block allocation method. Data collection involved a demographic questionnaire, the neonatal infant pain scale, and a pulse oximetry device. Friedman, Kruskal–Wallis, and Dunn’s post hoc tests employed for data analysis, with a significance level of P < 0.05.
Results
The use of oral sucrose and kangaroo care demonstrated significant differences in breathing rate, heart rate, and average arterial blood oxygen saturation during and after venipuncture (P < 0.05). Oral sucrose was found to be significantly more effective than kangaroo care. Neonates under kangaroo care exhibited more regular heart rates compared to the other group (P < 0.05). The utilization of oral sucrose and kangaroo care had varying effects on the average pain score resulting from venipuncture in premature neonates (P < 0.05).
Conclusions
Both methods proved effective in reducing pain and improving physiological variables. However, due to the superior effectiveness of sucrose administration, it is recommended as a cost-effective and easily implementable method in NICUs.
Trial registration: Iranian Registry of Clinical Trials IRCT20191215045749N1. (29/03/2020).
Keywords: Premature infant, Oral sucrose, Kangaroo mother care, Venipuncture, Neonatal intensive care units
Introduction
Some infants are often hospitalized for weeks or months in neonatal intensive care units (NICUs) and undergo multiple painful procedures as part of their routine care that can impact their physiological responses [1–3]. These procedures have the potential to negatively affect physiological variables such as plasma cortisol level, oxygen saturation, heart rate, and breathing rate, as well as behavioral parameters including crying and body movements. Premature infants, with their immature nervous system, are particularly vulnerable to the long-term effects of pain, highlighting the importance of effective pain management during the neonatal period [4].
Pain assessment is the fifth vital sign and must be accurately assessed to implement effective pain management strategies. Recent research has recommended updating evidence-based strategies for pain management using non-pharmacological interventions such as the administration of sweet solutions [5]. Various non-pharmacological methods have been reported to be effective in alleviating pain in premature infants during painful procedures. One widely recommended approach is the use of oral sucrose, which has been shown to be safe and effective in reducing behavioral pain responses in infants during painful procedures [6]. Another method is the kangaroo mother care, which involves skin-to-skin contact between parents and infants as an alternative to conventional care in NICUs provides optimal growth conditions for infants and promotes bonding between parents and infants. The intimate contact and pleasant tactile stimulation during kangaroo care lead to the release of oxytocin, which regulates brain and systemic changes in both the infant and kangaroo care provider [7]. In addition, the newborn experiences the comforting sounds of the mother's heart and rhythmic breathing, warmth, and the prone position during skin-to-skin contact, which provides subtle stimulation to the auditory, tactile, vestibular, and thermal sensory systems. These mechanisms help calm the infant, stabilize physiological variables, and reduce the number of breaths [8]. Kangaroo care has been associated with reduced neonatal mortality, infections, hypothermia, and length of hospital stay, as well as improved parent–infant bonding, breastfeeding, and weight gain [8–10]. Other benefits include stabilization of heart rate, improved blood oxygen saturation, breathing rate, and infant feeding, as well as increased maternal milk production [11, 12]. Several trials and recent systematic reviews with meta-analyses have demonstrated the effectiveness and safety of sweet solutions, including oral sucrose, in reducing pain intensity during single and tissue-damaging procedures in infants [13, 14].
Solutions for pain relief in NICUs are often recommended in infant pain guidelines [15]. Combining multiple non-pharmacological interventions may be more effective in pain reduction than using a single method, as sensory saturation through multisensory stimulation can enhance pain relief [16–18]. In addition, in family-centered care, presence and involvement and participation of a member of family in the care, especially neonates’ mother is emphasized. Therefore, when it is necessary to perform invasive procedures such as venipuncture in NICUs, participation of family to reduce pain is logical and acceptable [19–21]. However, research supporting this theory has yielded conflicting results. Therefore, the aim of this study was to compare the effects of oral sucrose and kangaroo mother care on selected physiological variables and pain scores resulting from venipuncture in premature infants admitted to NICUs.
Materials and methods
This randomized controlled clinical trial aimed to compare the effects of oral sucrose and kangaroo mother care on selected physiological variables and pain scores resulting from venipuncture in premature infants admitted to Hazrat Zainab and Hafez Hospitals, affiliated with Shiraz University of Medical Sciences, Shiraz, Iran. The sample size was determined based on similar studies [22, 23], resulting in 22 participants in each group to account for a 20% dropout rate, α = 0.05, β = 0.2, and 80% power. The study flowchart is illustrated in Fig. 1.
Fig. 1.
Flowchart of trial
As shown in Fig. 1, randomization and attrition data were organized according to CONSORT (Consolidated Standards of Reporting Trials) guidelines.
Inclusion criteria consisted of premature infants with a gestational age of 28–37 weeks (including days after birth), birth weight of ≥ 1500 g, absence of congenital defects, Apgar score of 7–10 in the first and fifth minutes, oral feeding ability, absence of painful procedures within 1 h prior to the study, no delay in intrauterine growth, presence of sucking reflex and response to painful stimulation, absence of diabetes mellitus and necrotizing enterocolitis in the neonate, no use of pharmaceutical or non-pharmaceutical pain control measures within the last 24 h, postnatal age of 48 h or more, mother who did not smoke, consume alcohol or drugs during pregnancy, willingness to cooperate, and absence of specific underlying disease in the mother. Exclusion criteria included infant death or illness, need for mechanical ventilation or continuous positive airway pressure, parental unwillingness to continue participation, blood sampling from more than one location, abnormal physiological responses such as heart rate exceeding 200 or falling below 80, or a decrease in arterial oxygen saturation below 80% during the intervention were considered the exclusion criteria. Neonates were assigned to three groups based on permutation block method and the randomization list for blinding and random assignment. The intervention groups received either kangaroo care (n = 22) or oral sucrose (n = 22, while the control group received routine care without any intervention.
In this study, we examined the demographic information of newborns, including date of birth, birth weight, fetal age, age and weight at the beginning of the study, sex, first- and fifth-minute Apgar scores, duration of admission, and type of delivery. To assess pain, we utilized the neonatal infant pain scale (NIPS) tool. This tool measures behavioral signs of pain in both full-term and premature babies during acute invasive procedures, and it can be is used for up to 6 weeks after birth. The scale evaluates crying, facial expressions, breathing pattern, movements of hands, legs, and the state of arousal. It consists of three options: zero, one, and two for crying (zero: calm, one: moaning, two: intense crying), and zero and one for the remaining five options (facial expressions, breathing pattern, hand movements, leg movements, and state of arousal). The neonatal infant pain scale was initially developed by Lawrence and colleagues in 1993 [24]. Several studies have been conducted to establish the validity and reliability of this tool. Suraseranivongse and colleagues evaluated its reliability by employing the simultaneous observation method with two observers, yielding a Pearson's correlation coefficient of 89%, indicating acceptable reliability [25]. Other researchers have also affirmed the potential use of this tool in the ICU, with a reported Spearman–Brown correlation coefficient of 86%, indicating good reliability [26].
To record heart rate and oxygen saturation percentage before, during, and after venipuncture, we employed the Novametrix model 520 A pulse oximetry device. To determine its validity, it was measured and checked by two people separately with two traditional measurement methods by touching the pulse and measurement by pulse oximetry device. One device was used for all newborns. The reliability of the device was ensured through confirmation and calibration by the medical engineering unit of the hospital. Physiological variables, including heart rate, oxygen saturation percentage, and breathing rate, were recorded using a checklist. In this study, filming was conducted 5 min before or after the bleeding, capturing the infant's body and the pulse oximeter readings. The recorded videos were then reviewed by an independent observer, who was blinded to the group assignment. This observer assessed the infant's pain score and recorded the heart rate and oxygen saturation data. This approach ensured single-blind blinding in the study. In addition, a high-quality video camera (Canon A3200 IS) was utilized to record the physiological response of the infant, venipuncture was performed between 8 and 9 a.m. by a skilled and experienced personnel. Infants in the kangaroo care group received kangaroo care from their mothers 75 min before blood sampling. Several physiological variables (respiration rate, heart rate, and oxygen saturation) were measured 5 min before, during, and 5 min after venipuncture. After KMC mothers left the wards due to laws of NICUs in our hospitals which emphasize not presence of family members during conducting painful procedures to support their mental health. The researcher used a high-quality video camera to film the baby's face and body, while the physiological variables were measured and recorded by a pulse oximetry device. Filming began 5 min before to the venipuncture and continued for 5 min afterward. In the oral sucrose group, 2 drops of 24% oral sucrose solution was administered on the anterior part of the tongue using a syringe 2 min before intravenous habituation. Physiological variables were measured 5 min before, during, and 5 min after blood sampling. In both test groups, the pain level was measured by an experienced nurse using NIPS tool, in conjunction with monitoring oxygen saturation percentage, breathing rate, and heart rate. In the control group, routine care was performed, and physiological variables and pain scores were measured before, during, and 5 min after the venipuncture.
Ethical considerations
The study adhered to the ethics code IR.SUMS.REC.1398.1197.
Statistical analyses
The data were analyzed with SPSS software, version 25. For data that did not follow a normal distribution, the non-parametric Kruskal–Wallis test was used. To compare the mean of physiological variables between and within the groups, Kruskal–Wallis, Friedman, and Dunn's post-hoc tests were used. A significance level of P < 0.05 was considered statistically significant.
Results
Based on the study results, there was no statistically significant difference in the demographic characteristics of the participating infants among the three groups, indicating their similarity at baseline (Table 1).
Table 1.
Demographic variables of the participants in both groups
| Variable | Group | P value | ||
|---|---|---|---|---|
| Kangaroo care N = 22 |
Oral sucrose N = 22 |
Control N = 22 |
||
| Birth weight | 3216.13 ± 1276.99 | 2129.91 ± 442.90 | 2040.45 ± 306.92 | 0.526* |
| Gestational age | 32.42 ± 2.11 | 33.41 ± 1.84 | 33.40 ± 2.06 | 0.130* |
| Age at study | 33.87 ± 1.88 | 32.42 ± 1.70 | 34.53 ± 2.01 | 0.453* |
| Weight at study | 1898.46 ± 365.30 | 1992.82 ± 419.60 | 1845.45 ± 273.24 | 0.542* |
| One-minute Apgar | 7.50 ± 0.597 | 8.00 ± 0.872 | 7.86 ± 0.833 | 0.117* |
| Five-minute Apgar | 8.05 ± 1.21 | 8.63 ± 1.05 | 8.68 ± 0.893 | 0.073* |
| Hospital admission duration | 10.28 ± 6.06 | 7.45 ± 5.91 | 7.77 ± 4.41 | 0.126* |
| Sex | ||||
| Boy | 12 (54.5%) | 10 (45.5%) | 13 (59.1%) | 0.653† |
| Girl | 10 (45.5%) | 12 (54.5%) | 9(40.9%) | |
| Delivery type | ||||
| Cesarean section | 16 (72.7%) | 15 (68.2%) | 17 (77.3%) | 0.795† |
| Natural vaginal delivery | 6 (27.3%) | 7 (31.8%) | 5 (22.7%) | |
*Kruskal–Wallis test
†Chi-square test
The Kruskal–Wallis test results showed that mean breathing rate, heart rate, oxygen saturation, and pain scores before blood sampling did not significantly differ between the three groups (P > 0.05). However, the average breathing rate, heart rate, oxygen saturation, and pain score during and 5 min after blood sampling were significantly different among the three groups (P < 0.05, Table 2).
Table 2.
Comparison of physiological variables and pain in the study groups, before, during, and 5 min after the venous blood sampling
| Variable | Group | ||||
|---|---|---|---|---|---|
| Status | Kangaroo care (N = 22) |
Oral sucrose (N = 22) |
Control (N = 22) |
P value between the groups | |
| Mean ± SD | Mean ± SD | Mean ± SD | |||
| Breathing rate | Before blood sampling | 49.68 ± 3.18 | 49.54 ± 4.17 | 48.55 ± 2.50 | 0.645* |
| During blood sampling | 52.82 ± 3.31 | 47.37 ± 4.65 | 51.27 ± 2.58 | < 0.0001* | |
| Five minutes after blood sampling | 51.59 ± 4.18 | 46.72 ± 4.79 | 49.91 ± 3.55 | 0.006* | |
| P value within the groups | < 0.0001† | 0.002† | 0.001† | ||
| Number of heartbeats | Before blood sampling | 165.32 ± 10.55 | 157.68 ± 11.08 | 158.45 ± 13.51 | 0.120* |
| During blood sampling | 169.91 ± 10.41 | 152.95 ± 12.05 | 160.45 ± 15.08 | < 0.0001* | |
| Five minutes after blood sampling | 169.63 ± 10.41 | 151.95 ± 11.91 | 165.09 ± 12.83 | < 0.0001* | |
| P value within the groups | < 0.0001† | < 0.0001† | < 0.0001† | ||
| Oxygen saturation | Before blood sampling | 94.73 ± 2.05 | 95.73 ± 1.55 | 95.68 ± 2.19 | 0.133* |
| During blood sampling | 92.68 ± 2.14 | 96.41 ± 1.89 | 94.32 ± 2.76 | < 0.0001* | |
| Five minutes after blood sampling | 92.00 ± 2.58 | 95.68 ± 1.70 | 94.50 ± 2.84 | < 0.0001* | |
| P value within the groups | < 0.0001† | 0.004† | 0.011† | ||
| Pain score | Before blood sampling | 2.55 ± 0.81 | 2.13 ± 0.83 | 2.59 ± 1.47 | 0.356* |
| During blood sampling | 4.41 ± 0.66 | 2.59 ± 1.05 | 4.36 ± 1.09 | < 0.0001* | |
| Five minutes after blood sampling | 3.50 ± 1.05 | 1.68 ± 1.17 | 3.36 ± 1.67 | < 0.0001* | |
| P value within the groups | < 0.0001† | 0.006† | < 0.0001† | ||
significant values are bold
*Kruskal–Wallis test
†Freidman test
Follow-up tests revealed that during blood sampling, the average respiration rate, heart rate, oxygen saturation, and pain score in the oral sucrose group significantly differed from the kangaroo care group (P < 0.0001). In addition, a statistically significant difference was observed between the oral sucrose group and the control group (P < 0.05). Five minutes after the blood sampling, the average breathing rate, heart rate, oxygen saturation, and pain score in the oral sucrose group significantly differed from the kangaroo care group (P < 0.0001). Similarly, a statistically significant difference was noted between the oral sucrose group and the control group (P < 0.05).
In the kangaroo care group, the Friedman’s test indicated significant differences in the mean breathing rate, heart rate, oxygen saturation, and pain score at baseline, during blood sampling, and 5 min after blood sampling (P < 0.0001). The follow-up test showed that the average breathing rate, heart rate, oxygen saturation, and pain score in the kangaroo care group had significant differences between before blood sampling and during or 5 min after blood sampling (P < 0.05). However, no statistically significant difference was observed during the blood collection and 5 min after the blood collection (P > 0.05).
In the oral sucrose group, the results of the Friedman’s test results demonstrated significant differences in the mean breathing rate, heart rate, oxygen saturation, and pain score before, during, and 5 min after blood sampling (P < 0.05). Follow-up tests indicated that the average breathing rate, heart rate, oxygen saturation, and pain score before blood significantly differed from the average breathing rate during and 5 min after blood sampling (P < 0.05). While no significant statistical difference was found during blood collection and 5 min after the blood collection (P > 0.05). For the control group, the Friedman's test revealed significant differences in the average breathing rate, heart rate, oxygen saturation, and pain score before, during, and 5 min after blood sampling (P < 0.05). The follow-up test demonstrated that the average breathing rate, heart rate, oxygen saturation, and pain score during blood sampling significantly differed from the average breathing rate before the blood sampling and 5 min after the blood sampling (P < 0.05).
Discussion
The present study examined the effects of oral sucrose and kangaroo care on the respiratory rate of premature infants during venipuncture. The results showed that oral sucrose was significantly more effective in reducing the respiratory rate compared to kangaroo care. This finding is consistent with a study that found lower breathing rates in infants receiving kangaroo care compared to those in incubator care [27]. Both kangaroo care and sucrose administration had a significant impact on the respiratory rate, suggesting that these interventions can influence the physiological variable of breathing rate compared to no intervention. During the blood sampling and 5 min after, the average heart rate in the oral sucrose group differed significantly from both the kangaroo care and control groups. Another study also reported significant effects of oral sucrose on physiological variables and heart rate in premature infants, indicating a return to normal function compared to the control group [28], which is in line with the results of our study. A meta-analysis showed that the average breathing rate of premature infants receiving kangaroo care was lower than that of infants receiving standard care in the incubator, and the average heart rate of infants who received kangaroo care had higher oxygen levels and heart rate [29]. Another study showed that kangaroo care has been shown to reduce the heart rate, breathing rate, crying and wakefulness in infants, while increasing oxygen saturation levels and sleep duration [7]. In addition, it is effective in controlling physiological variables such as heart rate and arterial oxygen saturation [30], which is in line with the results of our study. In a clinical trial, the attachment behaviors program in the NICU has been found to improve physiological variables of the neonates, suggesting its usefulness for infants admitted to these units [22]. In addition, studies have shown that the heart rate of babies under kangaroo care is more regular than that of babies who do not receive such care [31], and these findings and our study support the effectiveness of both kangaroo care and sucrose administration in influencing physiological variables, including heart rate.
The administration of breast milk and sucrose compared to local anesthesia was reportedly less effective in adjusting physiological variables such as oxygen saturation and tissue perfusion; it has been recommended to provide pharmaceutical interventions to relieve the pain caused by invasive interventions in neonates [32]. The contradictory results of some studies can be attributed to the type of procedure. In this regard it is important to note that in infants, because of their specific physiological conditions, choosing an effective method, and its safety and non-invasiveness should also be taken into consideration.
Regarding blood oxygen saturation, our study found that during blood sampling and 5 min after, the average blood oxygen saturation of the oral sucrose group has a significant difference with the average blood oxygen saturation of the kangaroo care and control groups. In this regard, a similar study that was conducted showed that babies who were born at 28 weeks of gestation and 4 weeks have passed since their admission in the NICU, had decreased behavioral responses to painful stimuli and increased heart rate, and decreased arterial blood oxygen saturation [8]. Painful procedures in infants can lead to short-term physiological consequences, such as decreasing arterial blood oxygen saturation and increasing heart rate, which can increase demands on the cardiopulmonary system [9]. Overall, the use of oral sucrose and kangaroo care during venipuncture of premature infants had different effects on physiological variables, including heart rate, respiration rate, and blood oxygen saturation.
Oral sucrose solution has potential analgesic effects during painful procedures such as taking blood from babies and can also reduce heart rate. It stimulates the sweet taste receptors of the tongue, leading to the release of endogenous opioids and pain relief effect through opioid receptors located on the tongue. The soothing effect of sucrose lasts for about 10 min, with peak effectiveness observed about 2 min after administration sucrose. Numerous studies have demonstrated the effectiveness of sucrose in reducing pain in infants [33, 34]. For instance, a study by Kassab et al. showed significantly less pain in infants after immunization in the sucrose group compared to the placebo group [5]. Another study reported a 35% reduction in pain and an 88% reduction in crying duration following the use of kangaroo care during heel injection compared with the control group. The positive effect of kangaroo care on physiological parameters during heel lancets in infants; therefore, this non-pharmacological method can help nurses create an opportunity to improve physiological variables during heel lancets [35].
Moreover, we found that the use of oral sucrose and kangaroo care has a different effect on the average pain score caused by venipuncture in premature infants. In this regard, other studies indicated that the administration of sucrose before and during the painful procedure has a great effect on the pain response in term infants [36, 37]. The results of Golchin and colleagues’ study showed that the use of sucrose reduced the pain of babies during and after venipuncture and blood sampling [38]. In another study, pain scores during venipuncture in the sucrose and combination group (sucrose and music) were significantly lower than the control group [3], which is in line with the results of our study. Moreover, in one study kangaroo care and 50% oral dextrose were equally effective and superior to the supine position in reducing pain response in premature infants during heel lancet; therefore, each can be routinely used in NICUs and after delivery to reduce the pain of painful procedures [39]. Based on the results of a study comparing the analgesic effects of breast milk and sucrose on reducing pain during venipuncture, it was demonstrated that both methods are equally effective in alleviating pain in infants. The study found no significant difference between the two groups in terms of pain reduction during blood sampling [40].
Despite the positive effect of kangaroo care and sucrose administration in infants admitted to the NICU, our study had some limitations. These included challenges in obtaining informed consent from parents, maternal admission due to cesarean section, lack of maternal presence and ability to perform kangaroo care, fear of primiparous mothers in holding a premature babies due to the low weight of many babies, lack of cooperation from some newborn nurses, and the inability to take blood from the baby in the mother's arms.
Conclusion
Both oral sucrose administration and kangaroo care can significantly reduce pain and influence physiological variables in infants, with sucrose administration being more effective than kangaroo care. Due to the affordability and easy availability of sucrose, which can be administered by people without professional training, it is recommended to use this non-pharmacological method to improve physiological symptoms and alleviate pain caused by painful procedures such as venipuncture in premature infants. It is important to note that, according to the findings of other studies discussed, the effectiveness of oral sucrose in alleviating pain during venipuncture in neonates can be comparable to breastfeeding. Thus, the presence of the mother and the use of breastfeeding for pain relief and enhancing stability in neonatal intensive care units should also be highlighted.
Acknowledgements
The authors are also grateful for mothers of neonates and nurses of neonatal intensive care units for their kind cooperation in the study. This article is the result of a Master of Science thesis in Neonates Special Care major conducted by Narjes Nasri.
Author contributions
PGH. and ZH aided in the conceptualization, design, and critical revision of the final manuscript, ZH, ME, PGH and MR, aided in design, preparation of manuscript and critical revision of the final manuscript. ZH, NN aided in data analysis and critical revision of the final manuscript. All authors read and approved the final manuscript.
Data availability
In this questionnaire-based study, ethical approval was obtained from the [Iranian Registry of Clinical Trials IRCT20191215045749N1], ensuring that the researcher adhered to established ethical guidelines and principles. All respectable readers and researchers can request the data by directly contacting the primary author at zahra hadian shirazi with nursing.midwifery.school@gmail.com.
Declarations
Ethics approval and consent to participate
In this questionnaire-based study, ethical approval was obtained from the [Iranian Registry of Clinical Trials IRCT20191215045749N1], ensuring that the researcher adhered to established ethical guidelines and principles.
Consent for publication
The authors consent for publication.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Yurkovich J, Burns DS, Harrison T. The effect of music therapy entrainment on physiologic measures of infants in the cardiac intensive care unit: single case withdrawal pilot study. J Music Ther. 2018;55(1):62–82. [DOI] [PubMed] [Google Scholar]
- 2.Filippa M, Devouche E, Arioni C, Imberty M, Gratier M. Live maternal speech and singing have beneficial effects on hospitalized preterm infants. Acta Paediatr. 2013;102(10):1017–20. [DOI] [PubMed] [Google Scholar]
- 3.Barandouzi ZA, Keshavarz M, Montazeri A, Ashayeri H, Rajaei Z. Comparison of the analgesic effect of oral sucrose and/or music in preterm neonates: a double-blind randomized clinical trial. Complement Ther Med. 2020;1(48):102271. [DOI] [PubMed] [Google Scholar]
- 4.Shabani F, Nayeri ND, Karimi R, Zarei K, Chehrazi M. Effects of music therapy on pain responses induced by blood sampling in premature infants: a randomized cross-over trial. Iran J Nurs Midwifery Res. 2016;21(4):391. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Kassab M, Almomani B, Nuseir K. Efficacy of sucrose in reducing pain during immunization among 10-to 18-month-old infants and young children: a randomized controlled trial. J Pediatr Nurs. 2020;1(50):e55-61. [DOI] [PubMed] [Google Scholar]
- 6.Harrison DM. Oral sucrose for pain management in the paediatric emergency department; a review. Australas Emerg Nurs J. 2008;11(2):72–9. [Google Scholar]
- 7.Gebuza G, Kaźmierczak M, Leńska K. The effects of kangaroo mother care and music listening on physiological parameters, oxygen saturation, crying, awake state and sleep in infants in NICU. J Matern Fetal Neonatal Med. 2022;35(19):3659–69. [DOI] [PubMed] [Google Scholar]
- 8.Cho ES, Kim SJ, Kwon MS, Cho H, Kim EH, Jun EM, Lee S. The effects of kangaroo care in the neonatal intensive care unit on the physiological functions of preterm infants, maternal–infant attachment, and maternal stress. J Pediatr Nurs. 2016;31(4):430–8. [DOI] [PubMed] [Google Scholar]
- 9.Bastani F, Rajai N, Farsi Z, Als H. The effects of kangaroo care on the sleep and wake states of preterm infants. J Nurs Res. 2017;25(3):231–9. [DOI] [PubMed] [Google Scholar]
- 10.Sharma A. Efficacy of early skin-to-skin contact on the rate of exclusive breastfeeding in term neonates: a randomized controlled trial. Afr Health Sci. 2016;16(3):790–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Chan GJ, Valsangkar B, Kajeepeta S, Boundy EO, Wall S. What is kangaroo mother care? Systematic review of the literature. J Glob Health. 2016;6(1): 010701. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Jefferies AL, Canadian Paediatric Society, Fetus and Newborn Committee. Kangaroo care for the preterm infant and family. Paediatr Child Health. 2012;17(3):141–3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Stevens B, Yamada J, Ohlsson A, Haliburton S, Shorkey A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev. 2016. 10.1002/14651858.CD001069.pub5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Bueno M, Yamada J, Harrison D, Khan S, Ohlsson A, Adams-Webber T, Beyene J, Stevens B. A systematic review and meta-analyses of nonsucrose sweet solutions for pain relief in neonates. Pain Res Manag. 2013;18(3):153–61. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Stevens B, Yamada J, Campbell-Yeo M, Gibbins S, Harrison D, Dionne K, Taddio A, McNair C, Willan A, Ballantyne M, Widger K. The minimally effective dose of sucrose for procedural pain relief in neonates: a randomized controlled trial. BMC Pediatr. 2018;18(1):1–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Witt N, Coynor S, Edwards C, Bradshaw H. A guide to pain assessment and management in the neonate. Curr Emerg Hosp Med Rep. 2016;4:1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Perroteau A, Nanquette MC, Rousseau A, Renolleau S, Bérard L, Mitanchez D, Leblanc J. Efficacy of facilitated tucking combined with non-nutritive sucking on very preterm infants’ pain during the heel-stick procedure: a randomized controlled trial. Int J Nurs Stud. 2018;1(86):29–35. [DOI] [PubMed] [Google Scholar]
- 18.Bembich S, Cont G, Causin E, Paviotti G, Marzari P, Demarini S. Infant analgesia with a combination of breast milk, glucose, or maternal holding. Pediatrics. 2018;142(3): e20173416. [DOI] [PubMed] [Google Scholar]
- 19.HadianShirazi Z, Sharif F, Rakhshan M, Pishva N, Jahanpour F. Lived experiences of the caregivers of infants about family-centered care in the neonatal intensive care unit: a phenomenological study. Iran J Neonatol. 2018;9(1):13–23. [Google Scholar]
- 20.Shirazi ZH, Sharif F, Rakhshan M, Pishva N, Jahanpour F. Lived experience of caregivers of family-centered care in the neonatal intensive care unit: “evocation of being at home.” Iran J Pediatr. 2016;26(5): e3960. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Shirazi ZH, Soltanian M, Sarvestani RS. Relief and care in the shade: a concept extracted from practices of neonatal nurses during pain management. Nurs Pract Today. 2020. 10.18502/npt.v7i3.3349. [Google Scholar]
- 22.Edraki M, Zendeh-Zaban S, Pour NB, Hemati F, Haghpanah S. The effect of maternal attachment behaviors program on physiological indicators of preterm infants: a clinical trial. Sadra Med Sci J. 2017;4(1):11. [Google Scholar]
- 23.Rafati S, Rejeh N, Tadrisi SD, Karimi M, Molodi A. Effect of massage on physiological pain responses of blood sampling in infants. Iran J Nurs Res. 2015;10(2):45–53. [Google Scholar]
- 24.Lawrence J, Alcock D, McGrath P, Kay J, MacMurray SB, Dulberg C. The development of a tool to assess neonatal pain. Neonatal Netw. 1993;12(6):59–66. [PubMed] [Google Scholar]
- 25.Suraseranivongse S, Kaosaard R, Intakong P, Pornsiriprasert S, Karnchana Y, Kaopinpruck J, et al. A comparison of postoperative pain scales in neonates. Br J Anaesth. 2006;97(4):540–4. [DOI] [PubMed] [Google Scholar]
- 26.Sarhangi F, Mollahadi M, Ebadi A, Matinzadeh ZK, Tadrisi SD. validity and reliability of neonatal infant pain scale in neonatal intensive care units in Iran (2010). Pak J Med Sci. 2011;27(5):1087–91. [Google Scholar]
- 27.Cheraghi F, Pakseresht M, Parsa P, Basiri B. Effect of kangaroo mother care on premature newborns’ pain due to invasive procedures in neonatal intensive care unit of hospital Fatemieh, Hamadan. Sci J Ilam Univ Med Sci. 2014;22(1):31–40. [Google Scholar]
- 28.Valeri BO, Gaspardo CM, Martinez FE, Linhares M. Effectiveness of sucrose used routinely for pain relief and neonatal clinical risk in preterm infants. Clin J Pain. 2018;34(8):713–22. [DOI] [PubMed] [Google Scholar]
- 29.CristóbalCañadas D, Bonillo Perales A, GaleraMartínez R, del Casado-Belmonte MP, ParrónCarreño T. Effects of Kangaroo mother care in the NICU on the physiological stress parameters of premature infants: a meta-analysis of RCTs. Int J Environ Res Public Health. 2022;19(1):583. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Dezhdar S, Jahanpour F, Bakht SF, Ostovar A. The effects of kangaroo mother care and swaddling on venipuncture pain in premature neonates: a randomized clinical trial. Iran Red Crescent Med J. 2016;18(4): e29649. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Bergh A-M, Sylla M, Traore IMA, Diall Bengaly H, Kante M, Kaba DN. Evaluation of kangaroo mother care services in Mali. Report Washington (DC): Save the Children. 2012.
- 32.Turan O, Akkoyun I, Ince DA, Doganay B, Tugcu AU, Ecevit A. Effect of breast milk and sucrose on pain and perfusion index during examination for retinopathy of prematurity. J Matern Fetal Neonatal Med. 2021;34(7):1138–42. [DOI] [PubMed] [Google Scholar]
- 33.Liaw JJ, Zeng WP, Yang L, Yuh YS, Yin T, Meei-Horng Y. Nonnutritive sucking and oral sucrose relieve neonatal pain during intramuscular injection of hepatitis vaccine. J Pain Symptom Manag. 2011;42(6):918–30. [DOI] [PubMed] [Google Scholar]
- 34.van Sleuwen BE, L’Hoir MP, Engelberts AC, Busschers WB, Westers P, Blom MA, et al. Comparison of behavior modification with and without swaddling as interventions for excessive crying. J Pediater. 2006;149(6):512–7. [DOI] [PubMed] [Google Scholar]
- 35.Seo YS, Lee J, Ahn HY. Effects of kangaroo care on neonatal pain in South Korea. J Trop Pediatr. 2016;62(3):246–9. [DOI] [PubMed] [Google Scholar]
- 36.Ghoneim AA. Effects of sucrose and kangaroo care on pain alleviation among preterm neonates undergoing invasive procedures. Am J Nurs Sci. 2016;5:146–51. [Google Scholar]
- 37.De Bernardo G, Riccitelli M, Sordino D, Giordano M, Piccolo S, Buonocore G, Perrone S. Oral 24% sucrose associated with nonnutritive sucking for pain control in healthy term newborns receiving venipuncture beyond the first week of life. J Pain Res. 2019;8:299–305. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Golchin M, Bahrami P. The effect of combined use of nonnutritive sucking and sucrose on cardio-respiratory indices and pain behaviors during blood drawing-phlebotomy procedures in preterm infants undergoing intensive care. Anesthesiol Pain. 2016;7(2):41–54. [Google Scholar]
- 39.Kapoor A, Khan MA, Beohar V. Pain relief in late preterm neonates: a comparative study of kangaroo mother care, oral dextrose 50%, and supine nesting position. Int J Appl Basic Med Res. 2021;11(3):188–91. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Efe E, Savaser S. The effect of two different methods used duringperipheral venous blood collection on pain reduction in neonates. AGRI-ISTANBUL. 2007;19(2):49. [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
In this questionnaire-based study, ethical approval was obtained from the [Iranian Registry of Clinical Trials IRCT20191215045749N1], ensuring that the researcher adhered to established ethical guidelines and principles. All respectable readers and researchers can request the data by directly contacting the primary author at zahra hadian shirazi with nursing.midwifery.school@gmail.com.