Kangaroo Care for Preterm Infant Pain: Article Critique

Introduction and Research Background

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 information gaps related to the pain management of heel sticks performed on premature infants. This paper offers a comprehensive critique of the article and includes the study concepts, details, and implications for nursing practice.

For many preterm neonates — 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 one of the more painful procedures (Simons et al., 2003). As expected, most infants cry in response to the pain generated by 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 produce a number of negative physiologic effects that may 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 had been studied, very little information existed 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 was framed as a hypothesis: that preterm infants would have less crying time — either audible or inaudible — during a heel stick performed in Kangaroo Care compared to one performed in the incubator (Kostandy et al., 2008).

Literature Review and Author Critique

The literature review is presented throughout the article through the use of references — both parenthetical and in the reference 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. All of the references appear to be appropriate to the subject matter and help support the information stated.

The authors provided a critique of the study by highlighting its strengths and limitations and offering suggestions for future research. 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 current knowledge is provided, outlining crying as the common response to pain. The two types of crying — audible and inaudible — are defined. 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 and Design

Conceptual and operational study variables were also identified. The independent variables were the mother and the incubator, as the presence of either could change, or have an effect on, the dependent variable — the infant. An additional independent variable, which may be considered extraneous yet appears relevant to the study, was the health status and 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.

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., 2008). 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 indicated physiologic benefits of the procedure. However, the study highlighted in the article was not based on those prior studies but was conducted as its own pilot study. Originally, the study was intended to be a larger investigation, but due to lack of funding, only ten subjects could be enrolled: "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 existing information on infant pain response and to study the effects of KC as a pain management tool.

Conclusion

Clear and concise, the article "Kangaroo Care (Skin Contact) Reduces Crying Response to Pain in Preterm Neonates: Pilot Results" (Kostandy et al., 2008) provides extensive details on a pilot research study. Researchers sought to study the effectiveness of Kangaroo Care, a non-pharmacologic intervention, on pain management in preterm infants who experience frequent heel sticks. Key components of the study — including the materials and methods, variables, results, limitations, and clinical implications — were covered along with an extensive literature review consisting mostly of parenthetical references backed by relevant professional and industry sources.

The author critique outlined the strengths and weaknesses of the study, recognizing that the overall results were positive: "The pilot data reported here suggest that KC is effective in reducing the crying response to heel stick pain in medically stable premature infants" (Kostandy et al., 2008). However, one key message emerged throughout: there is still more research needed before Kangaroo Care can become a standard component of routine nursing practice.

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