Non-nutritive sucking and facilitated tucking relieve preterm infant pain during heel-stick procedures: a prospective, randomised controlled crossover trial.

Preterm infants' repeated exposure to painful procedures may contribute to negative consequences. Thus, improving preterm infants' neurodevelopmental outcomes requires prioritising their pain management. To compare the effectiveness of two non-pharmacological pain-relief strategies (non-nutritive sucking and facilitated tucking) with routine care on preterm infants' pain, behavioural, and physiological responses before, during, and after heel-stick procedures. Prospective, randomised controlled crossover trial. Level III Neonatal Intensive Care Unit in Taipei. Thirty-four preterm infants (gestational age 29-37 weeks) needing three procedural heel sticks were recruited by convenience sampling and randomly assigned to a sequence of three treatments (two pain-relief interventions and the control condition): (1) routine care, non-nutritive sucking, facilitated tucking, (2) non-nutritive sucking, facilitated tucking, routine care, and (3) facilitated tucking, routine care, non-nutritive sucking. Each treatment condition was performed on a different day to avoid any carry-over effect. Pain was measured by the Premature Infant Pain Profile (PIPP), infant behaviour by a behavioural coding scheme, and physiological signals by electrocardiogram monitors. All data were collected 3 min without stimuli (baseline), during heel-stick procedures, and recovery. Infants receiving non-nutritive sucking and facilitated tucking had significantly lower mean (standard deviation) pain scores during heel-stick procedures (6.39 [3.35] and 7.15 [3.88], respectively) than those receiving routine care (9.52 [4.95]). Infants receiving non-nutritive sucking and facilitated tucking had significantly lower odds ratios (0.39, p=0.011 and 0.34, p=0.005, respectively) for pain (PIPP score≥6) than infants receiving routine care after adjusting for time, baseline pain scores, and infants' characteristics. Similarly, infants receiving non-nutritive sucking and facilitated tucking had significantly lower odds ratios (0.23, p<0.001 and 0.28, p=0.03, respectively) for moderate-to-severe pain (PIPP score≥12) than infants receiving routine care. Infants receiving facilitated tucking had lower frequency ratios for stress-related behaviours, abnormal heart rates, and decreased oxygen saturation than infants receiving routine care. Both non-nutritive sucking and facilitated tucking effectively reduced pain scores more than routine care during heel-stick procedures. Non-nutritive sucking reduced PIPP pain scores more effectively than facilitated tucking. However, facilitated tucking showed broader effects not only on relieving pain, but also on enhancing infants' physiological and behavioural stability during heel-stick procedures.

Liaw JJ ，Yang L ，Katherine Wang KW ，Chen CM ，Chang YC ，Yin T ... -  《-》

Development of atraumatic heel-stick procedures by combined treatment with non-nutritive sucking, oral sucrose, and facilitated tucking: a randomised, controlled trial.

Preterm infants manifest pain and stress by behavioural agitation and state change. Few studies have explored the effects of combining nonpharmacological interventions, i.e. non-nutritive sucking, oral sucrose, and facilitated tucking, on infants' behaviours across painful procedures. To explore the effects of combined use of three nonpharmacological interventions (non-nutritive sucking, oral sucrose, and facilitated tucking) on infants' pain- and stress-related behaviours during four assessment phases: baseline, intervention, heel stick, and recovery. Prospective, randomised controlled trial. Level III neonatal intensive care unit in Taipei. A convenience sample of 110 infants (gestational age 27-37 weeks) needing heel sticks was randomly assigned to five combinations of nonpharmacological treatments: (1) routine care, (2) non-nutritive sucking+facilitated tucking, (3) oral sucrose+facilitated tucking, (4) non-nutritive sucking+oral sucrose, and (5) non-nutritive sucking+oral sucrose+facilitated tucking. Outcomes were infants' withdrawal or stress (grimace, limb and trunk extension or squirming) and approach or self-soothing (sucking, sucking search, or mouthing; hand holding or grasping; and hand to mouth, face) behaviours. The frequency of infants' withdrawal behaviours decreased significantly when they received combinations of nonpharmacological interventions before heel stick. Specifically, grimace frequency decreased by 32.2%, 30.6%, 19.7%, and 13.8% in infants receiving oral sucrose+non-nutritive sucking+facilitated tucking, non-nutritive sucking+oral sucrose, oral sucrose+facilitated tucking, and non-nutritive sucking+facilitated tucking, respectively, compared to those receiving routine care across assessment phases. Furthermore, infants' frequency of limb and trunk extension or squirming decreased by 24.0% when they received non-nutritive sucking+oral sucrose+facilitated tucking compared to those receiving routine care. Infants' frequency of approach behaviours did not change significantly across all phases when they received non-nutritive sucking+oral sucrose+facilitated tucking, non-nutritive sucking+oral sucrose, and oral sucrose+facilitated tucking compared to those receiving routine care. The combined use of nonpharmacological interventions (non-nutritive sucking+oral sucrose+facilitated tucking) effectively reduced the frequencies of infants' withdrawal behaviours, i.e. grimace and limb and trunk extension or squirming. Our results provide evidence supporting clinicians' incorporation of the combined use of facilitated tucking, oral sucrose, and non-nutritive sucking into clinical practice during painful procedures. Heel-stick procedures can be atraumatic when conducted while infants are stable and quiet, appropriately positioned, and stabilised and by offering facilitated tucking, oral sucrose, and non-nutritive sucking before gently sticking the heel and squeezing blood.

Yin T ，Yang L ，Lee TY ，Li CC ，Hua YM ，Liaw JJ ... -  《-》

Effects of combined use of non-nutritive sucking, oral sucrose, and facilitated tucking on infant behavioural states across heel-stick procedures: a prospective, randomised controlled trial.

Liaw JJ ，Yang L ，Lee CM ，Fan HC ，Chang YC ，Cheng LP ... -  《-》

Non-nutritive sucking, oral breast milk, and facilitated tucking relieve preterm infant pain during heel-stick procedures: A prospective, randomized controlled trial.

Preterm infant pain can be relieved by combining non-nutritive sucking (sucking), oral sucrose, and facilitated tucking (tucking), but the pain-relief effects of oral expressed breast milk (breast milk) are ambiguous. We compared the effects of combined sucking+ breast milk, sucking+breast milk+tucking, and routine care on preterm infant pain during and after heel-stick procedures. A prospective, randomized controlled trial. Level III neonatal intensive care unit and a neonatal unit at a medical center in Taipei. Preterm infants (N=109, gestational age 29-37 weeks, stable disease condition) needing procedural heel sticks were recruited by convenience sampling and randomly assigned to three treatment conditions: routine care, sucking+ breast milk, and sucking+breast milk+ tucking. Pain was measured by watching video recordings of infants undergoing heel-stick procedures and scoring pain at 1-min intervals with the Premature Infant Pain Profile. Data were collected over eight phases: baseline (phase 1, 10min without stimuli before heel stick), during heel stick (phases 2 and 3), and a 10-min recovery (phases 4-8). For infants receiving sucking+ breast milk, pain-score changes from baseline across phases 2-8 were 2.634, 4.303, 2.812, 2.271, 1.465, 0.704, and 1.452 units lower than corresponding pain-score changes of infants receiving routine care (all p-values <0.05 except for phases 6 and 7). Similarly, for infants receiving sucking +breast milk+ tucking, pain-score changes from baseline were 2.652, 3.644, 1.686, 1.770, 1.409, 1.165, and 2.210 units lower than corresponding pain-score changes in infants receiving routine care across phases 2-8 (all p-values <0.05 except for phase 4). After receiving sucking +breast milk +tucking and sucking +breast milk, infants' risk of mild pain (pain score ≥6) significantly decreased 67.0% and 70.1%, respectively, compared to infants receiving routine care. After receiving sucking +breast milk +tucking and sucking +breast milk, infants' risk of moderate-to-severe pain (pain score ≥12) decreased 87.4% and 95.7%, respectively, compared to infants receiving routine care. The combined use of sucking+breast milk +tucking and sucking+breast milk effectively reduced preterm infants' mild pain and moderate-to-severe pain during heel-stick procedures. Adding facilitated tucking helped infants recover from pain across eight phases of heel-stick procedures. Our findings advance knowledge on the effects of combining expressed breast milk, sucking, and tucking on preterm infants' procedural pain.

Peng HF ，Yin T ，Yang L ，Wang C ，Chang YC ，Jeng MJ ，Liaw JJ ... -  《-》

Efficacy of facilitated tucking combined with non-nutritive sucking on very preterm infants' pain during the heel-stick procedure: A randomized controlled trial.

Reducing acute pain in premature infants during neonatal care improves their neurophysiological development. The use of pharmacological and non-pharmacological analgesia, such as sucrose, is limited per day, particularly for very preterm infants. Thus, the usual practice of non-nutritive sucking is often used alone. Facilitated tucking could be an additional strategy to non-nutritive sucking for reducing pain. To the best of our knowledge, no randomized trial has compared the combination of facilitated tucking and non-nutritive sucking to non-nutritive sucking alone. To compare the efficacy of facilitated tucking in combination with non-nutritive sucking (intervention group) to non-nutritive sucking alone (control group) in reducing pain during the heel-stick procedure in very preterm infants. Prospective, randomized controlled trial. Level III and II neonatal care units, including the neurosensory care management program. Very preterm infants (gestational age between 28 and 32 weeks) were randomly assigned by a computer programme to the intervention or control group during a heel-stick procedure within the first 48 h of life. In both groups, infants were placed in an asymmetric position on a cushion; noise and light were limited following routine care. A heel-stick was performed first in the care sequence. In the intervention group, facilitated tucking was performed by a nurse or nursing assistant. The procedure was video recorded from 15 s (T-15 s) before the procedure until three minutes (T + 3 min) after the end of the procedure. Pain was blindly assessed by two independent specialist nurses. The primary outcome was the pain score evaluated 15 s before the procedure and 30 s immediately after by the premature infant pain profile (PIPP) scale. The secondary outcome was the pain score evaluated between T-15 s and T + 3 min by the DAN scale (a French acronym for the acute pain of a newborn). Sixty infants were included (30 in each group). The PIPP pain scores did not differ between the intervention group (median: 8.0; interquartile range (IQR): 6.0-12.0) and the control group (median: 9.5; IQR: 7.0-13.0, p = 0.32). Pain assessed by the DAN scale at T + 3 min was lower in the intervention group than in the control group (median: 0.3; IQR: 0.0-1.0 and 2.0; IQR: 0.5-3.0, respectively, p = 0.001). The combined use of facilitated tucking and non-nutritive sucking did not significantly alleviate pain during the heel-stick procedure. However, the addition of facilitated tucking facilitated faster pain recovery following the heel-stick procedure.

Perroteau A ，Nanquette MC ，Rousseau A ，Renolleau S ，Bérard L ，Mitanchez D ，Leblanc J ... -  《-》