Kangaroo Care (Skin Contact) Reduces

¶ … Kangaroo Care (Skin Contact) Reduces Crying Response to Pain in Preterm Neonates: Pilot Study

Using Kangaroo Care to Help Ease the Pain of Heel Sticks -- an Article Critique

In a 2008 article titled, "Kangaroo Care (Skin Contact) Reduces Crying Response to Pain in Preterm Neonates: Pilot Results," by Raouth R. Kostandy, Susan M. Ludington-Hoe, Xiaomei Cong, Amel Abouelfettoh, Carly Bronson, Allison Stankus, and Julia R. Jarrell, research was conducted to address the information gaps related to the pain management of heel sticks performed on premature infants. This scholarly paper offers a comprehensive critique of the article and includes the study concepts, details, and implications for nursing practice.

For many preterm neonates, or preterm infants who are less than four weeks old, heel sticks are often used for blood sampling. This process involves lancing and squeezing the infant's heel and is considered to be one of the more painful procedures (Simons et al., 2003.) As expected, most infants cry in response to the pain generated from this treatment, which, beyond general discomfort, has the potential to cause long-term effects, "The painful procedures in the early stages of development lead to long-term changes such as higher-level pain processing and pain-induced plasticity in the human brain," (Anand et al., 2006, Slater et al., 2006, Taddio et al., 1995, 1997; Weaver, Diorio, & Meaney, 2007.) Crying can also have a number of other negative physiologic effects that can affect the infant's brain, heart rate and blood pressure. (Dinwiddie, Pitcher-Wilmott, Schwartz, et al., 1979 & Hiraishi, Agata, Saito, et al., 1991).

For this reason, it was determined that research on this subject was necessary, "The management of preterm infant pain is a high priority (Breau et al., 2006), and interventions to reduce pain and minimize adverse response are needed" (Bruce & Franck, 2005; D'Apolito, 2006). A research study was conducted to determine how a non-pharmacologic, or natural, pain management intervention known as Kangaroo Care (KC) can help reduce preterm infant pain during the heel stick procedure. While some non-pharmacologic methods have been studied, there was still very little information on the effectiveness of these procedures or their usage in the nursing environment. The research objective of the study is stated above and the overall research question provided was more of a hypothesis, focusing on the idea that preterm infants would have less crying time, either audible or inaudible, with a heel stick that was performed in Kangaroo Care compared to a heel stick performed in the incubator (Kostandy et al., 2008).

Literature review

The literature review is presented throughout the article, through the use of references, both parenthetical and in the references section provided at the end of the article. References consisted primarily of journal articles as well as a few books. Approximately 34 of the 71 references cited were dated within five years of the 2008 article date. It appears that all of the references are appropriate to the subject matter and help support the information stated.

Author critique

Authors provided a critique of the study by highlighting the study strengths and limitations and providing suggestions for future studies. The overall consensus was that while the study had many strengths, it was still a pilot study and further research is required. According to the researchers, the "results should be considered with caution," (Kostandy et al., 2008).

A summary of the current knowledge is provided, outlining crying as the common response to pain. The two types of crying, audible and inaudible, are defined and while audible crying has been the most studied, little is known about the inaudible crying response, "In fact, no studies of the inaudible cry response to pain could be found," (Cignacco et al., 2006). Therefore, researchers used this study to continue observing the audible crying response and to gather new data on the inaudible crying response.

Study variables

Conceptual and operational study variables were also identified. Independent variables were the mother and the incubator, as the presence of either could change, or have an effect on, the dependent variable, which was the infant. An additional independent variable, which may be considered extraneous yet appears to be relevant to the study, was the health status and/or potential vocal obstruction of the infant, "Some preterm and acutely ill infants may not cry during heel sticks and other painful procedures, which may be due to depleted energy reserves or because of the presence of an endotracheal tube," (Johnston et al., 1999; McGrath, 1990.) Despite these obstacles, researchers could still measure crying response through stopwatch timing and by observing inaudible crying behaviors.

Study design

A quiet, low-lit neonatal intensive care unit (NICU) served as the setting where the infants were tested. Researchers used a prospective cross-over study design with random assignment. To ensure the highest possible equivalence among infants, researchers used a permuted block design (Chow & Liu, 1998.) Heel sticks were performed as either a Kangaroo Care heel stick (KCH) or an incubator heel stick (IH.) (Kostandy et al.) Since Kangaroo Care is intended to intervene between the infant and the heel stick procedure, it is considered an intervention.

Earlier studies on KC and pain response were conducted, indicating physiologic benefits of the procedure. However, the study highlighted in the article was not based on those prior studies but was its own pilot study instead. Originally, the study was intended to be a major study but due to the lack of funding, only ten subjects could be used. "Initially, twenty-six subjects were needed to detect moderate difference in crying time; however, funding permitted recruitment of only ten subjects," (Kostandy et al., 2008). The basis of the study was to delve further into the existing information on infant pain response as well as to study the effects of KC as a pain management tool.

Sample

The study sample consisted of 10 healthy mothers and infants of a single birth that met a range of key criteria, from gestational age (30-32 weeks and within 2-9 days of birth) and the absence of heel tissue inflammation to history of surgery or drug exposure (Andrews & Fitzgerald, 1994, 1999; Fitzgerald, Millard, & MacIntosh, 1988; Kostandy, et al., 2008.) A high percentage of the mothers were white, married, and had delivered via cesarean section. The method used to recruit the study subjects as well as sample mortality was not disclosed in the article. It was clear, however, that the chosen subjects were relatively healthy, "No subjects were on ventilator support or supplemental O2 during testing nor did they have any other comorbidity," (Kostandy et.al, 2008). The university and hospital Institutional Review Boards approved the study and both parents of each infant provided their written informed consent.

Implications for practice

The study indicates that the use of KC has the potential to offer a more natural and effective alternative to pain management for infants undergoing heel stick procedures. Although, when applying this method to nursing practice, researchers suggest proceeding carefully, "Neonatal intensive care unit's staff need to educate on pain practice guidelines to improve neonatal pain management interventions," (Carbajal, Gall, & Annequin, 2004). "Kangaroo Care has been recommended as a non-pharmacologic pain management strategy, but the evidence supporting its practice with preterm infants is still limited. Thus, the practice of KC during heel sticks should be monitored closely and variation in infant response anticipated," (American Academy of Pediatrics, 2006; Golianu, Krane, Seybold, et al., 2007; Johnston, Filion, & Nuyt, 2007; Leslie & Marlow, 2006).