Effectiveness of Facilitated tucking on pain and Physiological parameters during heel lancing among neonates

 

Jomini Joshy1, Omana MP2

1M.Sc. Nursing Student, 15th Batch, Govt. College of Nursing, Kottayam.

2Guide and Assistant Professor, Govt. College of Nursing, Kottayam.

*Corresponding Author E-mail: jominijoshy@gmail.com

 

 

ABSTRACT:

The present study was undertaken to determine the effectiveness of facilitated tucking on pain and physiological parameters during heel lancing among neonates. A quantitative research approach with quasi experimental research design was used for the study. The framework, Katherine Kolcaba’s theory of holistic comfort theoretically supported the study. The study was conducted among 70 (35 control and 35 experimental) neonates admitted in the nicu, selected by non-probability purposive sampling technique. Clinical data sheet, neonatal pain assessment scale and physiological parameters assessment scale were used for data collection. Content validity of the tools were established by validating ten experts in the field of pediatric nursing and medicine. The data were collected over a period of six weeks and were analyzed using descriptive and inferential statistics. Results of the study revealed that, facilitated tucking had a significant effect in reducing pain during heel lancing among neonates at 0.001 level. The results also revealed that facilitated tucking had a significant effect in maintaining heart rate and respiratory rate at 0.001 level, but could not find significant effects on SpO2.

 

KEYWORDS: Facilitated tucking, Pain, Physiological parameters, Neonates.

 

 


INTRODUCTION:

Newborn period is the most vulnerable phase of life. The unhealthy newborn demands high degree of skills and technology in a special care nursery or neonatal intensive care unit for their intact survival. As per vital statistics, worldwide there were 77.9 percentage neonatal intensive care unit admissions per 1000 live births. In India around 14.4% of newborn babies were admitted to intensive care units.1

 

Neonates who care in neonatal intensive care unit (NICU) are subjected to various painful diagnostic and therapeutic procedures as a part of their life saving treatments. Studies have showed that total number of painful procedures was 8.09±5.53 per baby per day and 68.32±64.78 per baby during hospital stay.

 

 

Most common painful procedures performed include heel lancing, venepuncture, endotracheal intubation, suctioning, lumbar puncture and screening for retinopathy of prematurity.2

 

Neonates underwent painful procedures will exhibit higher distress than older children. Pain experienced by newborns affects the heart rate, respiratory rate, blood pressure, and tissue oxygenation, potentially causing these parameters to decrease or increase. Hence the assessments of these changes are very necessary for accurate detection, prevention and management of pain in infants.3

 

Amongst the routine procedures heel lancing is commonly being practiced in neonatal care units (30%) for capillary sampling. The short and long term sequelae of the pain related to heel lancing necessitate that neonate's pain should be assessed and managed properly.4

The neonates are highly sensitive to pain. Repeated exposure to heel lancing will affect bio-behavioural and physiological responses of the neonates and place them under the risk of short-term as well as long term effects, which include feeding problems, parent-infant interaction dysfunction, impairments of neurodevelopment, learning, memory etc.5

 

Administration of analgesics is controversial in neonates due to the potential detrimental side effects. Non-pharmacological interventions are accessible, inexpensive and have shown varying degrees of efficacy.6

 

Facilitated tucking is the simplest and cost effective technique, simulating the condition of being in-utero. This makes the baby comfortable 8 and secure with controlled responses and facilitates self-regulation by decreasing the physiologic response like increased heart rate which contributes to the disequilibrium associated with pain and stress. Also, it improves the emotional security and effectively reduces the pain perception in babies during painful procedures.7

 

Recent studies have focused only on pain physiology, pain assessment and pharmacological intervention not on procedural pain control and assessment of infants. Studies related to facilitated tucking and its effectiveness on pain and physiological parameter among neonates was scanty. Thus it is essential to contribute newer practices in neonates to reduce procedural pain that confines the neonates, to be significant and also prevent the long term consequences of repeated painful stimuli.

 

STATEMENT OF PROBLEM:

Effectiveness of facilitated tucking on pain and physiological parameters during heel lancing among neonates admitted in a tertiary care hospital, Kottayam.

 

OBJECTIVES:

1.     To assess the level of pain during heel lancing among neonates.

2.     To assess the physiological parameters during heel lancing among neonates.

3.     To determine the effect of facilitated tucking on pain during heel lancing among neonates.

4.     To determine the effect of facilitated tucking on physiological parameters during heel lancing among neonates.

 

HYPOTHESES:

H1:   There is a significant difference in pain during heel lancing among neonates, between control and experimental group.

H2:   There is a significant difference in physiological parameters during heel lancing among neonates, between control and experimental group.

METHODOLOGY:

Research approach:

Quantitative research approach.

 

Research design:

Quasi experimental post test only control group design.

 

Setting of the study:

Neonatal intensive care unit, medical college hospital, Kottayam.

 

Population:

Neonates admitted in neonatal intensive care unit undergoing heel lancing.

 

Sample and sample size:

The sample consists of seventy neonates admitted in the neonatal intensive care unit of medical college hospital, Kottayam undergoing heel lancing. There were 35 samples each in the control and experimental group.

 

Sampling technique:

Non probability purposive sampling technique.

 

Sampling criteria:

Inclusion criteria:

·       Neonates between 38-42 weeks of gestation

·       Neonates whose mothers are willing to participate in the study

·       Neonate’s mothers who are able to understand Malayalam

 

Exclusion criteria:

Neonates:

·       Underwent minor or major surgical procedures

·       Who are on mechanical ventilation

·       Under sedation

·       Who are on analgesics

·       Underwent painful procedures within an hour

·       Immediately after breast feeding

·       Previous exposure to heel lancing

 

Description of tools:

Tool 1: Clinical data sheet:

It is an investigator prepared clinical data sheet consist of gestational age, chronological age, gender, birth weight, mode of delivery and mode of feed

 

Tool 2: Neonatal Pain Assessment Scale:

The neonatal pain assessment scale is prepared by the investigator for assessing pain of neonates after reviewing the literature. It uses the behaviours that are indicative of infant pain or distress. It is composed of five (5) indicators that are facial expression, crying, arms, legs and state of arousal. This tool is prepared with consultation of experts in paediatrics and paediatric nursing.

 

Tool 3: Physiological Parameters Assessment Scale:

It consists of 4 parameters heart rate, respiratory rate and spo2, where the parameters are assessed before and after the procedure and check for variations.

 

Data collection procedure:

After obtaining permission from the concerned authority, study was started. Data collection process extended over a period of 6 weeks from 05/03/2021 to 10/04/2021. Following the pilot study, total of 70 neonates, 35 each in control and experimental groups satisfying the inclusion criteria were selected randomly. Baseline physiological parameters of the samples including heart rate, respiratory rate and SpO2 were collected using digital pulse oxymeter. Control group received routine care. Experimental group was given facilitated tucking during heel lancing. Then pain assessment and physiological parameters assessment were done with the help of Neonatal Pain Assessment Scale and Physiological Parameter Scale respectively within one minute of heel lancing.

 

Analysis of the data:

Section 1:

·       Most of the neonates in both experimental group (51.4%) and control group (45.7%) born during 38-39 weeks of gestation.

·       All neonates in both control and experimental group belong to the age group of 1-7days. Majority of neonates in control (60%) group are females.

·       In the experimental group 60% neonates are males and 40% are females.

·       Among the neonates 77.1% in control group and 94.3% in experimental group had a birth weight of 2.5-3.5 kg.

·       All neonates in control group and experimental group born by lower segment caesarean section and are on direct breast feed.

 

Section 2

·       In the control group 54.3% neonates experience severe pain, 40% experience moderate pain and 5.7% experience mild pain.

·       In the experimental group 51.4% experience mild pain, 25.7% experience moderate pain, 20% neonates experience no pain, and 2.9% experience severe pain.

·       Most of the neonates in the control group (48.6%) and experimental group (71.4%) have heart rate between 131-150/mt.

·       Among the neonates 57.1% in control group have respiratory rate between 51-60/mt, and 42.9% have respiratory rate between 41 - 50/mt.

·       In experimental group majority of neonates (57.1%) have respiratory rate between 41- 50/mt.

·       Majority of neonates (97.1%) in both control group and experimental group have >92% spo2 during heel lancing

Section 3

Table 1: Mean rank, sum of rank and Mann Whitney U value of pain during heel lancing among neonates in control and experimental group (n=70)

Group

Pain

Mean rank

Sum of rank

U value

Control (n=35)

50.94

1783

72***

Experimental (n=35)

20.06

702

*** Significant at 0.001 level

 

Table 1 showed that the obtained U value of pain during heel lancing among neonates is significant at 0.001 level. Hence the null hypothesis is rejected. That means there is a significant difference in pain during heel lancing among neonates, between control and experimental group. Therefore it can be interpreted that facilitated tucking is effective on pain during heel lancing among neonates.

 

Table 2: Mean rank, sum of rank and Mann Whitney U value of heart rate during heel lancing among neonates in control and experimental group (n=70)

Group

Heart rate

Mean rank

Sum of rank

U value

Control (n=35)

43.90

1536.50

 

 

 

318.50***

Experimental (n=35)

27.10

948.50

 

 *** Significant at 0.001 level

 

Table 2 shows that the obtained U value of heart rate during heel lancing among neonates is significant at 0.001 level. Hence the null hypothesis is rejected. That means there is a significant difference in variation of heart rate during heel lancing among neonates, between control and experimental group. Therefore it is evident that facilitated tucking is effective on maintaining heart rate during heel lancing among neonates.

 

Table 3: Mean rank, sum of rank and Mann Whitney U value of respiratory rate during heel lancing among neonates in control and experimental group (n=70)

Group

Respiratory rate

Mean rank

Sum of rank

U value

Control (n=35)

52.80

1848

 

 

 

 

7***

Experimental (n=35)

18.20

637

 

*** Significant at 0.001 level

 

Table 3 shows that the obtained U value of respiratory rate during heel lancing among neonates is significant at 0.001 level. Hence the null hypothesis is rejected. That means there is a significant difference in variation of respiratory rate during heel lancing among neonates, between control and experimental group. It can be interpreted that facilitated tucking is effective on maintaining respiratory rate during heel lancing among neonates.

 

 

Table 4: Mean rank, sum of rank and Mann Whitney U value of Sp02 during heel lancing among neonates in control and experimental group (n=70)

Group

SpO2

Mean rank

Sum of rank

U value

Control (n=35)

31.84

1114.50

 

 

 

 

484.50

Experimental (n=35)

39.16

1370.50

 

 

Table 4 shows that the obtained U value of SpO2 during heel lancing among neonates is not significant at 0.05 level. Hence the null hypothesis is accepted. That means there is no significant difference in SpO2 during heel lancing among neonates, between control and experimental group. It can be interpreted that facilitated tucking have no effect on SpO2 during heel lancing among neonates.

 

DISCUSSION:

The aim of the present study was to find out the effectiveness of facilitated tucking on pain and physiological parameters during heel lancing among neonates admitted in a tertiary care hospital, Kottayam.

 

Pain during heel lancing among neonates was assessed in terms of facial expression, crying, arms, legs and state of arousal. Sample size was 70 with 35 subjects each in control and experimental group. Babies belonged to the age group of less than 28 days and most of the neonates in both control group (45.7%) and experimental group (51.4%) born during 38-39 weeks of gestation. All neonates in both control and experimental group belonged to the age group of 1-7days.

 

Majority of the neonates in the control group (54.3%) experienced severe pain whereas in the experimental group majority of them (51.4%) experienced mild pain. In the control group 40% had moderate pain and 5.7% had mild pain. In the experimental group 51.4% experienced mild pain, 25.7% had moderate pain and 20% neonates had no pain. On reviewing literature, the investigator had come across similar studies. In a randomized controlled crossover study conducted to assess the effects of facilitated tucking on procedural pain in neonates showed that most of the neonates experienced severe pain during procedures without intervention but very few of them experienced severe procedural pain with facilitated tucking. The study concluded that the facilitated tucking position can be used as a safe non-pharmacological method of pain relief in neonates. 

 

The findings of the present study was congruent with another descriptive study conducted at Vancouver to identify the effect of neonatal procedural pain in 54 preterm neonates and 22 term neonates who had many painful procedures during early infancy. Salivary cortisol was measured before and at 20minutes after introduction of novel toys and after developmental assessment. Results showed that salivary cortisol was significantly higher in preterm neonates and significant (p<0.001), compared with term neonates (p<05). Findings proved that higher basal cortisol level in preterm neonates was associated with higher number of neonatal skin-breaking procedures during the early neonatal period. This study also showed that the impact of painful experience continue to persist even for long time.

 

In the present study physiological parameters in terms of heart rate, respiratory rate and SpO2 were assessed against physiological parameters assessment scale. Findings showed that most of the neonates in the experimental group (71.4%) and control group (48.6%) had normal heart rate between 131-150/mt. In case of respiratory rate, 57.1% of neonates in control group have respiratory rate between 51-60/mt, and 42.9% neonates have respiratory rate 41-50/mt. In experimental group majority of neonates (57.1%) have respiratory rate between 41-50/mt. The data discovered that majority of neonates (97.1%) in both control group and experimental group have >92% SpO2 during heel lancing.

 

A similar experimental study conducted in Iran among 70 neonates, who needed routine blood collection. The neonate’s pain, HR and SpO2 were measured two minutes before and three minutes after the blood collection and their maximum level was recorded. The results showed that the mean changes in HR and SpO2 were significantly different between control and experimental groups (p = 0.001), i.e. were lower in the experimental group who receives facilitated tucking.

 

In the present study pain during heel lancing was assessed with the help of neonatal pain assessment scale. In this study investigator determined that facilitated tucking was effective on pain during heel lancing among neonates.

 

The findings of the study are supported by a systematic review conducted in Sao Paulo to determine the efficacy of facilitated tucking for non-pharmacological pain management in 120 neonates. Facilitated tucking was provided and parameters were assessed before, during and after the procedure. The results showed that there is a significant difference between control and experimental groups (p = 0.001) in pain and heart rate during painful procedures.

 

Similarly an experimental study was conducted in Asan hospital, Korea to assess the effectiveness of facilitated tucking on pain and physiological parameters among 60 neonates. The pain scores were analysed using Neonatal Infant Pain Scale. The study found that facilitated tucking significantly reduced the heart rate and pain scores and comforting the neonates to have self-regulated response over repeated painful stimulus during heel lancing hence enforced to promote facilitated tucking as a routine part of painful procedures. But, saturation had no significant differences (Z=3.230, p=.000).

 

Findings of the above literature showed that facilitated tucking has significant effect on reducing pain during heel lancing among neonates. In the present study also, facilitated tucking results reduction in level of pain during heel lancing. Results of the present study are consistent with the literature findings.

 

The effectiveness of facilitated tucking on physiological parameters during heel lancing among neonates was assessed with the help of physiological parameters assessment scale. In the present study investigator determined that facilitated tucking was effective on maintaining heart rate and respiratory rate during heel lancing among neonates but have no effect on SpO2.

 

The findings of the study is concordant with an experimental study conducted in a level III neonatal intensive-care unit of a tertiary care university paediatric hospital assessed the effectiveness of facilitated tucking as a comfort measure in modulating neonates' physiologic and behavioural responses to minor pain. Heart rate, oxygen saturation, and sleep state of neonates were recorded 12 minutes before, during, and 15 minutes after heel pricks. Neonates demonstrated a minimal variations in heart rate 6–10 minutes post-stick (p< 0.04), shorter mean crying time (p< 0.001), shorter mean sleep disruption time (p < 0.001), and fewer sleep-state changes (p=0.003) after heelprick with facilitated tucking than without. The study suggested that facilitated tucking is an effective comfort measure in attenuating premature neonates' psychologic and behavioural responses to minor pain. Also facilitated tucking is effective on maintaining physiological parameters during heel lancing among neonates in terms of heart rate, respiratory rate and SpO2. The Mann Whitney U test was done for the post test scores of physiological parameters of neonates between control and experimental group. The obtained U value was significant at 0.001 levels for all parameters except SpO2.

 

Similar to this a randomized controlled trial conducted in Saudi Arabia among 135 neonates to compare the effectiveness of facilitated tucking and oral dextrose water during heel lancing. Pain responses were measured using a behavioural pain scale. Also physiological pain responses (heart rate, respiratory rate, and oxygen saturation) were recorded. The results showed that neonates with facilitated tucking were effective in reducing behavioural scores (P=0.00) and physiological pain scores, including heart rate (P= 0.009), respiratory rate (P=0.01), and oxygen saturation (P=0.002) as compared to control group.

Another similar finding is in a prospective, randomised controlled crossover trial conducted in a level III Neonatal Intensive Care Unit in Taipei, to compare the effectiveness of two non-pharmacological pain-relief strategies (non-nutritive sucking and facilitated tucking) during heel lancing. Study was conducted in 34 neonates with routine care. The dependent variables were neonate’s pain, behavioural, and physiological responses before, during, and after heel-stick procedures. The results showed that facilitated tucking had broader effects not only on relieving pain, but also on enhancing infants’ physiological and behavioural stability during heel-stick procedures than infants receiving routine care.

 

So the present study and the existing literature reviewed conclude that facilitated tucking is effective in reducing pain responses and maintaining physiological parameters during heel lancing among neonates.

 

RECOMMENDATIONS:

·       Similar study can be replicated on a larger sample

·       Similar interventions can be used during other kinds of acute painful procedures

·       Similar study can be conducted in another setting

·       Comparative study can be done to find out effect of facilitated tucking with other non-pharmacological methods of pain management

·       Similar studies can be replicated by using different assessment tools.

·       Study can be replicated to compare the effectiveness of facilitated tucking on preterm and term neonates.

 

CONCLUSION:

The study on effectiveness of facilitated tucking on pain and physiological parameters during heel lancing among neonates admitted in a tertiary care hospital, 70 Kottayam was a successful research work by the investigator. Based on the findings of the study, the following conclusions were drawn. There was a significant difference in pain during heel lancing among neonates, between control and experimental group. It can be concluded that facilitated tucking is effective on pain during heel lancing among neonates. The present study highlighted the need for pain management for the neonates during heel lancing. Facilitated tucking helps the neonates to maintain heart rate and respiratory rate during heel lancing. So more researches should be conducted and utilized by the nursing professionals in their clinical practice to reduce the level of procedural pain in neonates at the NICU and neonatal wards

 

REFERENCES:

1.      National Perinatal Information System/Quality Analytic Services; www.npic.org. Prepared by March of Dimes Perinatal Data Center, 2011.

2.      Britto CD, Rao PN S, Nesargi S, Nair S, Rao S, Thilagavathy T, Ramesh A, Bhat S. PAIN—perception and assessment of painful procedures in the NICU. Journal of Tropical Pediatrics. 2014 Dec 1; 60(6):422-7.

3.      Kliegman, Behrman, Jenson, Stanton. Nelson text book of pediatrics. 18th ed. Philadelphia: Saunders; 2008.p.475, 713.

4.      Carbajal R, Chauvet X, Couderc S, Olivier-Martin M. Randomised trial of analgesic effects of sucrose, glucose, and pacifiers in term neonates. BMJ. 1999 Nov 27; 319 (7222):1393-7

5.      Raeside L. Physiological measures of assessing infant pain: a literature review. British Journal of Nursing. 2011 Nov 23; 20(21):1370-6.

6.      Rubin Selvarani G. Effectiveness of facilitated tucking on level of pain among preterm infants undergoing painful procedure at selected hospitals, Chennai, 2015 (Doctoral Dissertation, Omayal Achi College of Nursing, Chennai).

7.      Kucukoglu S, Kurt S, Aytekin A. The effect of the facilitated tucking position in reducing vaccination-induced pain in newborns. Italian Journal of Pediatrics. 2015 Dec 1;41(1):61.

 

 

 

Received on 24.04.2022           Modified on 09.05.2022

Accepted on 19.05.2022          © A&V Publications all right reserved

Int. J. Nur. Edu. and Research. 2022; 10(3):249-254.

DOI: 10.52711/2454-2660.2022.00058