A TRUE EXPERIMENTAL STUDY TO ASSESS THE EFFECTIVENESS OF FACILITATED TUCKING POSITION ON LEVEL OF PAIN
PERCEPTION DURING PENTAVALENT VACCINATION AMONG THE INFANTS IN
SELECTED HOSPITAL OPD IN ERODE
BY
301717101
A DISSERTATION SUBMITTED TO THE TAMILNADU DR M.G.R MEDICAL UNIVERSITY, CHENNAI IN PARTIAL FULLFILMENT OF THE REQUIREMENT FOR THE AWARD OF THE DEGREE OF MASTER OF SCIENCE IN NURSING.
OCTOBER – 2019
A TRUE EXPERIMENTALSTUDY TO ASSESS THE EFFECTIVENESS OF FACILITATED TUCKING POSITION ON LEVEL OF PAIN PERCEPTION DURING
PENTAVALENT VACCINATION AMONG THE INFANTS IN SELECTED HOSPITAL OPD IN ERODE.
BY 301717101
Research & Clinical Speciality Guide: _________________________
PROF.MRS.M.KAVIMANI, M.S.N, RN, RM, (PH.D)
SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF THE DEGREE OF MASTER OF SCIENCE IN NURSING FROM THE TAMILNADU
DR.M.G.R.MEDICAL UNIVERSITY, CHENNAI.
OCTOBER – 2019
DECLARATION
This is to certify that the dissertation entitled “A TRUE EXPERIMENTAL STUDY TO ASSESS THE EFFECTIVENESS OF FACILITATED TUCKING POSITION ON LEVEL OF PAIN PERCEPTION DURING PENTAVALENT VACCINATION AMONG THE INFANTS IN SELECTED HOSPITAL OPD IN ERODE.” is a bonafide work done By 301717101, Shivparvathi Mandradiar Institute of Health Science, in partial fulfilment of the university rules and regulations for award of Master of Science in Nursing under the guidance and supervision during the year of OCTOBER - 2019
Signature of the Head of the Department:
Signature of the Principal:
DECLARATION
I hereby declare that the present dissertation titled, “A TRUE EXPERIMENTAL STUDY TO ASSESS THE EFFECTIVENESS OF FACILITATED TUCKING POSITION ON LEVEL OF PAIN PERCEPTION DURING PENTAVALENT VACCINATION AMONG THE INFANTS IN SELECTED HOSPITAL OPD IN ERODE” outcome of the original research work undertaken and carried out by me, under the guidance of Research guide and clinical specialty guide Prof. MRS. KAVIMANI, M.S.N, R.N, R.M, (PH.D) Shivparvathi Mandradiar Institute of Health Sciences, College of Nursing.
I hereby declare that the material of this has not found in anyway, the basis for the award of any degree/diploma in this University or any other University.
301717101
CERTIFIED THAT THIS IS THE BONAFIDE WORK OF 301717101
AT THE SHIVPARVATHI MANDRADIAR INSTITUTE OF HEALTH
SCIENCE, COLLEGE OF NURSING
SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF THE DEGREE OF
MASTER OF SCIENCE IN NURSING FROM TAMIL NADU DR.M.G.R. MEDICAL UNIVERSITY,
CHENNAI.
Examiners:
1. _________________________
2. __________________________
ACKNOWLEDGEMENT
“I will give thanks to you Lord, with all heart; I will tell you all your wonderful deeds.”
First of all I thank and praise God Almighty for His Love, Compassion, and giving me the real treasure of wisdom, courage, endurance and abundant blessings throughout my career and personal life.
Apart from the effort of me, the success of my study comes from every soul who encouraged and guided me in all the aspects. I, the Investigator take the opportunity to express my gratitude to the successful completion of this project.
It is my privilege to remember our chairman (Late) Sri. A. Shivakumar Mandradiar and also express my special thanks to Mr.Naveen Mandradiar, Secretary, Mrs. Mano Mandradiar Correspondent, Mrs.Pallavi Mandradiar Trustee and Mr.Balasubramanian, Manager, SPMIHS, Palayakottai, for the opportunity given to pursue Master Degree in this institution.
I proudly and honestly express my deep sense of gratitude to our esteemed leader Prof. M. Kavimani, Principal, SPMIHS, Palayakottai, for her excellence guidance, sustained patience, and valuable suggestions, encouragement and timely support throughout the study. I am indebted to her constant interest, untiring guidance, valuable suggestions, continuous support and encouragement to complete this research work.
I express my warm thanks to Associate Professor Mrs R. Ramalakshmi M.Sc. (N), Assistant Lecturer Miss K.Girija M sc. (N), and Assistant Lecturer Mrs.VijayaSandhiya of SPMIHS for their support and guidance.
I am indeed thankful to Prof. Dr.Dhanapal, Bio-Statistician, SPMIHS, Palayakottai, for his guidance in carrying out the necessary statistical analysis and presentation of the data in the study.
I would like to thank the office staff Mrs.Saranya and Ms.Akila Maheswari for their contribution during my course of study.
I would like to thank Mrs.Jamuna, Librarian for extending library facilities throughout the study.
I recognise and appreciate all the staffs and batch mates for the help, cooperation and guidance whenever needed.
I extend my warm and heartfelt thanks to all the participants, who have willingly shared their precious time during the process of data collection, without their kind cooperation it would have been impossible for me to go ahead with this study.
I express my profound thanks to all my friends and well-wishers for their unconditional love and support in every step of the project.
Words are beyond expression for the meticulous, I express my love and gratitude to my beloved mother Late Shephali Murmu and lovable Dad Mr.Bimal Kisku for their inspiration, continuous support, unending love, special prayers, constant encouragement and strength by always being my backbone whenever I
needed, which made my study, a dream come true and I extend my warmest gratitude to my lovely sisters Ms. Sarah, Ms. Kristina, and Ms. Violet who were always there for me to support me and my sincere thanks to my other family members.
I am grateful towards the administrators of Care 24 Hospital at Erode for granting permission to conduct the study upon their babies.
My grateful thanks are extended to all the mothers along with their babies who participated in the study without whose active cooperation it would not have been impossible to develop into the personal nature of this inquiry.
I take this opportunity to express my gratitude to everyone who supported me throughout the course of this project. I am thankful for their aspiring guidance, invaluable constructive criticism and friendly advice during the project work. I sincerely thank them for sharing their truthful and illuminating views on a number of issues related to the project.
301717101
TABLE OF CONTENTS
CHAPTER NO
CONTENTS PAGE
NO
I
INTRODUCTION Background of the Study Need for the Study
Statement of the Problem Objectives of the Study Hypothesis of the Study Assumptions
Delimitations
Operational Definition Conceptual Frame Work Summary
II
REVIEW OF LITERATURE
Section A: Studies related to pain perception among infants.
Section B: Studies related facilitated tucking position on pain among infants.
III
RESEARCH METHODOLOGY Research Approach
Research Design Variables
Research Setting Population
Sample & Sample size Sampling Technique Sampling Criteria Development of the Tool Description of the Tool Validity
Reliability Pilot Study
Data Collection Procedure Ethical Consideration Plan for Data Analysis Summary
IV
DATA ANALYSIS AND INTERPRETATION
Data on Selected Demographic Variables of the infants in Control and Experimental Group.
Data on comparison of level of pain perception during Pentavalentvaccination among infants in Control and Experimental group.
Data on effectiveness of facilitated tucking position on level of pain perception among infants in
Experimental Group.
Data on Association between the level of pain perception and the Selected Demographic Variables among infants in Control Group and Experimental Group
SUMMARY, FINDINGS, DISCUSSION, IMPLICATION, LIMITATION,
V
RECOMMENDATION AND CONCLUSION Summary
Findings Discussion Implication Limitation
Recommendation Conclusion
REFERENCE Text book Dictionary Journals
Electronic Sources
APPENDICES/ANNEXURES
LIST OF TABLES
TABLE NO
TITLES PAGE
NO 1 Schematic representation
2 Scoring on Neonatal Infant Pain Scale 3 Plan for data analysis
4.1 Frequency and Percentage Distribution of maternal variables in Control and Experimental Group.
4.2 Frequency and Percentage Distribution of clinical variables of infants in Control and Experimental group.
5 Mean, Standard Deviation, Mean difference, and Mean Percentage values regarding level of pain perception during Pentavalent vaccination among infants in Control and Experimental Group.
6 Mean, Mean difference, Standard Deviation and Unpaired ‘t’ Value regarding Post Test on level of Pain Perception in Control and Experimental Group.
7.1 Frequency, Percentage Distribution and Chi-Square Association between the level of pain and the Selected Demographic Variables among infants in Control Group.
7.2 Frequency, Percentage Distribution and Chi-Square Association between the level of pain perception and the Selected Demographic Variables among infants in Experimental Group.
8 NIPS Score
9 Steps of intervention
LISTS OF FIGURES
SR.NO TITLE PAGE
.NO.
1. Conceptual framework of the study.
2. Schematic representation of research design
3. Frequency and Percentage Distribution of Age of the Infants in the Control Group and Experimental Group
4. Frequency and Percentage Distribution of Gender of the Infant in the Control Group and Experimental Group
5. Frequency and Percentage Distribution on Gestational age of the Infant in Control and Experimental group
6. Frequency and Percentage Distribution on Birth weight of the Infant in Control and Experimental group
7. Frequency and Percentage Distribution on Birth Order of Infant in Control and Experimental Group
8.
Frequency and Percentage Distribution on Type of feeding among the infants in experimental and control group
9. Frequency and Percentage Distribution on Last Feed given in Control group and Experimental group
10 Data On Comparison Of Level Of Pain Perception During Pentavalent Vaccination Among Infants In Control And Experimental Group
LIST OF ANNEXURE
APPENDICES TITLE
1 Letter Seeking Permission to Conduct the Main Study 2 Letter seeking expert opinion on content validity of the tool.
3 Content Validity Certificate 4 Letter Granting Permission 5 List of Experts
6 Informed Written Consent form : English
7 Structured Interview on infant, maternal, and clinical variable- English
Demographic Variables Proforma
Modified Neonatal Infant Pain Scale 8 Intervention Protocol
9 Protocol on Facilitated Tucking Position
10 Photo Gallery
LIST OF ABBREVIATIONS
SHORT FORMS ABBREVIATION
SPMIHS Shivparvathi Mandradiar Institute of
Health Sciences
No Number
DPT Diphtheria Pertussis Tetanus
Hib Haemophilus influenza type b
GAVI Global Alliance for Vaccines and
Immunizations
GoI Government of India
HBV Hepatitis B virus
NICU Neonatal Intensive Care Unit
NI Neonatal Infection
BCG Bacillus Calmette-Guerin
Fig Figure
H01, H02,H03 Research Hypothesis
M.Sc. (N) Master of Science in Nursing
NIPS Neonatal Infant Pain Scale
n Total number of samples
r Reliability
f Frequency
% Percentage
𝛘2 Chi-square test
SD Standard Deviation
MD Mean Difference
P Probability
< Less than
> Greater than
S Significant
NS Not Significant
df Degree of freedom
ABSTRACT
A True Experimental study to assess the effectiveness of facilitated tucking position on level of pain perception during Pentavalent vaccination among the infants in selected hospital OPD in Erode was done by 301717101 as a partial fulfilment of the requirement of the degree of Master of Science in Nursing at Shivparvathi Mandradiar Institute of Health Science, under the Tamil Nadu Dr. MGR Medical University, Chennai, October – 2019
The Objectives of the Study were
1. To assess the level of pain perception during Pentavalent vaccination among infants in control and experimental group.
2. To compare the level of pain perception during Pentavalent vaccination among infants in control and experimental group.
3. To assess the effectiveness of facilitated tucking position on level of pain perception during Pentavalent vaccination among infants in experimental group.
4. To find out the association between the level of pain perception and the selected demographic variable among the infants receiving Pentavalent vaccination in control and experimental group.
Hypothesis for the Study were
H01: There is no significant relationship between the facilitated tucking position and level of pain perceptionduring Pentavalent vaccination among infants in experimental group.
H02: There is no significant difference in the level of pain perception during Pentavalent vaccine among infants in control and experimental group.
H03: There is no significant association between selected demographic variables and the level of pain perception among infants receiving Pentavalent vaccination in control and experimental group.
Theconceptual framework for the present study was derived fromThe Gate Control Theory of Pain. The present study was a quantitative research approach and evaluative in nature. It was a true experimental post-test control group design. For the present study, independent variable of the study was facilitated tucking position and dependent variable was level of pain perception during Pentavalent vaccination among infants.
A modified NIPS score and the demographic variables Performa were used to collect the data by structured interview schedule and observation. The content validity of the tool was established by 5 experts in the field. Reliability was assessed by interrater method and the reliability r = 0.85 was found to be reliable for modified NIPS Score. Pilot study was done on 10 samples, which fulfilled sample selection criteria which were other than the study samples. The study was found to be feasible and there were no practical difficulties during data collection.
The main study was conducted in CARE 24 Hospital OPD at Erode. The data collected were manually analysed, tabulated and interpreted and validated by the Bio- statistician. The mean pain score of post-test level of pain perception in theinfants who got vaccinated with facilitated tucking was 3.42 which were significantly less than mean pain score of post-test level of pain 5.32 in the infants who got vaccinated
without tucking position. The standard deviation for control group was 0.85 and mean percentage was 76% and for the experimental group the standard deviation was 0.95 and mean percentage was 68%.Among control group overall mean score was 5.32 and among experimental Group overall mean score was 3.42, Mean Difference was 1.9 and Standard Deviation was 0.1. The calculated unpaired ‘t’ value was 9.59 which was found to be statistically significant at p<0.05 level which indicates that there was a significant difference in the level of pain perception between the experimental and control group. It was inferred that there was significant reduction in the level of pain perception among the infants with facilitated tucking position. There was no significant association between the selected demographic variables in both control group and experimental group.
301717101
1
CHAPTER I
INTRODUCTION
“Children are a blessings and a gift from the Lord”
— The Bible.
An infant is specialised synonym for "baby" which is derived from Latin word that means “speechless” or “unable to speak”. Infants become children and children grow out to become adolescents, the diverse areas of growth and development is interrelated. All aspects of physical, psychological, emotional, psychosexual, spiritual, intellectual, cognitive, moral, language and speech- interact in various ways that may affect the other in the normal advance towards maturity.
Background of the Study
Pain is as an unpleasant physical feeling that occurs in varying degrees of severity as a result from injury, diseases, or psychological disorder. The word pain comes from the Latin word 'poena' which means punishment, a fine, or a penalty;
which triggers the psychological problem solving methods that seek to resolve the painful experience.
The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage.
2 There are two types of pain:
a. Nociceptive pain arises when tissue injury leads to activation of the nociceptors, which are sensitive to noxious stimuli. This type of pain can be divided into somatic and visceral pain.
1. Somatic pain is caused by the activation of nociceptors in surface of the tissues or in the deep tissues such as bone, joint, muscle or the connective tissue
2. Visceral pain is caused by the activation of nociceptors located in the viscera.
It can occur due to infection, distension from fluid or gas, stretching or compression of the organs, mostly from solid tumours.
b. Neuropathic pain is caused by damage to the structure and function of the nerve cell in the peripheral or central nervous system (CNS).
Classification that is based on duration of the pain; are acute pain that lasts for less than 30 days, and chronic pain that lasts for more than three months.
Acute pain is of sudden onset, which is felt immediately following injury, is severe in intensity and is usually short-lasting. It arises as a result of tissue injury stimulating the nociceptors and generally disappears when the injury heals.
Chronic pain is persistent pain that lasts beyond the expected normal time of healing.
Consequences of pain in the infants may cause immediate effects such as irritability, fear, disturbance of sleep, wakefulness, increased oxygen consumption,
3
Ventilation and perfusion mismatch, diminished nutrient intake and increased gastric acidity. Short term effects such as enhanced catabolism, altered immunological function, delayed healing; impaired emotional bonding may occur. Long term effects may be memories of pain, developmental retardation, alteration in response to subsequent painful experience.
Management strategies for pain in infants have to be taken into consideration.
Non-pharmacological interventions to relieve infant pain can be practiced like positioning and restraining the infant in a relatively flexed posture, stimulation of nerve fibres transmitting tactile and thermal sensations, combining these methods with soothing vocal stimulation, breast feeding, feeding of sweet compounds such as sucrose, glucose and saccharine, non-nutritive sucking on pacifiers.
According to National Institute of Health (NIH) Pain is a signal in the nervous system that conveys that something may be wrong in the body. It is an unpleasant feeling, such as a prick, sting, burn, or ache on any part of the body. It usually comes and goes frequently, or it may be persistent. It can be felt in one part of the body, such as back, abdomen, chest, pelvis, or all over. The two types of pain:
acute pain and chronic pain may arise in an individual. Acute pain usually is sudden in nature; it may be because of diseases, injuries, or inflammation. It can usually be diagnosed and it can be treated. It usually goes away, but sometimes it can turn into chronic pain. Chronic pain lasts for a longer duration, and can cause severe problems.
Pain is not often curable, but there are many ways to manage it. Management depends on the cause and type of pain. There are pharmacological treatments, including pain relievers. There are also non-pharmacological treatments, like acupuncture, physical therapy, and sometimes surgery.
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American Academy of Paediatrics (2016) reported that pain that newborns experience from routine medical procedures can be significant, especially in premature infants with more intensive health needs. Researchers advocate that recurrent exposure to pain in early life span can create changes in development of the brain. Because of this, a new American Academy of Paediatrics policy statement recommends every health facility caring for newborns should use several strategies to minimize the number of painful procedures performed, and routinely monitor and treat pain with greater emphasis on proven non-pharmacological interventions.
Potera (2010) documented that pain was untreated in children recovering at home following tonsillectomy or adenoidectomy. Parents used various pain rating scales to indicate when their children were experiencing pain, but only 24% of the 86% who were experiencing significant pain were medicated or received even one dose of the prescribed analgesic. This may have been due to the fact that parents did not recognize that their children were in pain or were reluctant to administer pain medication to young children for fear they may become dependent on it.
Need for the Study
Vaccinations are first administered from the time of birth. Some studies have shown that uncontrolled pain that is experienced during the early stages of life can have negative and long-term side effects, such as distress, and such pain can negatively affects the development of the central nervous system. Some physiological parameters, behavioural methods, and stress hormones have been evaluated to express the pain felt by newborns.
5
Assessment of pain in preverbal children is difficult, especially in neonates, because the most reliable indicator of pain, self-report is not possible. Crying associated with pain is more intense. Facial expression is the most specific and certain characteristics. Most infants respond with increased body movements. Infants respond to painful stimuli through physiologic indicators, behavioural indicators (muscle rigidity, facial expression, crying withdrawal and sleeplessness). In infants with diminished ability to respond forcefully to pain, it is important to suppose that pain exists in all situation that are usually considered painful for adults and children even if there is absence of behavioural or physiologic signs.
World Health Organization (WHO) reported that about 86% of the infants’
globally (116.3 million infants) received 3 doses of Diphtheria Pertussis Tetanus (DPT 3) vaccine that protected them against infectious diseases that could have caused serious illness and disability. By 2018, 129 countries had reached 90%
coverage of DTP 3 vaccine. In 2017 the number of children immunized were 116.2 million which was the highest ever reported. Since 2010, 113 countries have introduced new vaccines, and more than 20 million children have been vaccinated.
Because of low coverage nationally, multiple WHO regions have been hit with large measles and diphtheria outbreaks causing many deaths. The continued detection of poliovirus is further evidence that national immunization programmes are not achieving the goal of reaching every child. The immunization community must seek to reach its aim to do more better things. Immunization is a back bone of universal health coverage, which provides an infrastructure for effective and equitable health systems worldwide. Immunization contributes to multiple development goals, global health security and the battle against antimicrobial resistance.
6
In July 2014, South Sudan introduced Pentavalent vaccine. Kenya was the first to launch the vaccine with the help of GAVI support in 2001.In 2000; less than 10% of low-income countries had introduced hepatitis B vaccine and Pentavalent vaccine. Less than 5% had launched the Hemophilus influenzae type B vaccine as the part of their immunization programs. Today, all the world's poorest countries have introduced the two vaccines as part of the Pentavalent vaccine. Pentavalent vaccine coverage in GAVI and its supporting countries increased from 1% in 2000 to 80% in 2017. By the end of 2017, more than 404 million children had been immunized with Pentavalent vaccines that was funded by GAVI. Pentavalent vaccine has taken over Diphtheria Tetanus Pertussis (DPT) vaccine. GAVI started offering the vaccine in 2001 to boost the low uptake of hepatitis B and Hemophilus influenzae type B vaccines in developing countries by making them part of their routine immunization programs.
According to UNICEF (2012) Globally, Hemophilus influenzae type B kills more than 370,000 children less than five years of age every year. Nearly 20% of these children die in India due to Hemophilus influenzae type B. The survivors of this disease are often permanently paralysed, become deaf or get brain damaged.
Hemophilus influenzae type B vaccine can prevent over a 3rd of pneumonia cases and 90% of Hemophilus influenzae type Band meningitis cases in children. The Pentavalent vaccine protects against five possible killer diseases – Diphtheria,
Tetanus, Pertussis, Hemophilus influenzae type B, and Hepatitis B. Giving Pentavalent vaccine will reduce the number of pricks to child.
Nair, Hazarika, Patwari (2011) states that introduction of Hemophilus influenzae type B containing Pentavalent vaccines in the Universal Immunization
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Program (UIP) was a far sighted decision taken in 2009 by the Ministry of Health and Family Welfare, Government of India. This decision was based on the recommendations of National Technical Advisory Group on Immunization (NTAGI) and was aimed at reducing the burden of Hemophilus influenzae type B related infections. The decision was supported by the GAVI Alliance (formerly known as the Global Alliance for Vaccines and Immunizations) and in August 2009 they decided to provide funding worth US$ 165 million to the Government of India to support the introduction of Pentavalent vaccine. The vaccine was to be introduced in a phased manner. In the first phase, the vaccine would have been rolled-out in 10 states and an estimated 18 million infants were expected to receive the vaccine. The decision of the Indian Government to introduce Hemophilus influenzae type B vaccination into its UIP was hailed internationally by public health practitioners as India constitutes 34%
of the birth cohort in GAVI-eligible countries and even in the absence of population- based data, the country is estimated to have the highest number of deaths due to Hemophilus influenzae type Bin children under 5 years of age.
National Technical Advisory Group on Immunization (2008) recommended the inclusion of Pentavalent vaccine in UIP, depending on the availability of vaccines. Following the recommendation, the GoI decided to launch Hemophilus influenzae type B containing Pentavalent vaccines in ten states. The decision was hailed internationally by public health practitioners as India constitutes 34% of the birth cohort in GAVI-eligible countries and even in the absence of population- based data; the country is estimated to have the highest number of deaths due to Hemophilus influenzae type Bin children under 5 y of age. After initial controversies, India has introduced Pentavalent vaccine in two states (Tamil Nadu and
8
Kerala) through routine immunization program in the year 2011. Acknowledging the significance of Hemophilus influenzae type B vaccination, now the GoI has decided to introduce Hemophilus influenzae type B vaccine in UIP as liquid Pentavalent vaccine in six states, namely, Gujarat, Haryana, Karnataka, Goa, Jammu, Kashmir and Pondichery from October 2012 to December 2014.
The investigator had observed while working in the clinical field that the infants who were given vaccinations cried for longer duration due to pain than the older children. The investigator sensed that infant cannot speak out their pain and so they needed special understanding to feel their pain, so the investigator came up with a thought of taking up an interventional study which could aid in decrease in the pain level among the infants when they received vaccinations specially during Pentavalent vaccination as it is a combination of 5 vaccines and it might have more pain effect.
Hence the investigator had taken the study on effectiveness of facilitated tucking position during Pentavalent vaccination which is simple and easy to perform.
Statement of the Problem
A True Experimental Study to Assess the Effectiveness of Facilitated Tucking Position on Level of Pain Perception During Pentavalent Vaccination among the Infants in Selected Hospital OPD in Erode.
Objectives of the Study
1. To assess the level of pain perception during Pentavalent vaccination among infants in control and experimental group.
9
2. To compare the level of pain perception during Pentavalent vaccination among infants in control and experimental group.
3. To assess the effectiveness of facilitated tucking position on level of pain perception during Pentavalent vaccination among infants in experimental group.
4. To find out the association between the level of pain perception and the selected demographic variable among the infants receiving Pentavalent vaccination in control and experimental group.
Hypothesis for the Study
H01: There is no significant relationship between the facilitated tucking position and level of pain perception during Pentavalent vaccination among infants in experimental group.
H02: There is no significant difference in the level of pain perception during Pentavalent vaccine among infants in control and experimental group.
H03: There is no significant association between selected demographic variables and the level of pain perception among infants receiving Pentavalent vaccination in control and experimental group.
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Operational Definition
Effectiveness
It is the capability of producing a desired result or the ability to produce desired output.
In
this study, it refers to decrease in the level of pain perception after providing tucking position to the infants.Facilitated tucking position
It is holding the infant’s arms and legs in flexed position close to the midline
of body.
In this study, it refers to the provision of flexion of the leg to the infants during vaccination.
Pain Perception
It refers to ability to feel the unpleasant sensory and emotional experience associated with actual or potential tissue damage.
In this study, it refers to ability to feel the unpleasant stimuli during vaccination which is being measured by modified NIPS score which is inferred as no pain, mild, moderate and severe pain.
Infant
A child who is in the earliest stage of extrauterine life, a time extending from the first month after birth to approximately 12 months of age, when the baby is able to assume an erect posture.
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In this study, it refers to the babies between 6 weeks to 18 weeks of extrauterine life.
Pentavalent Vaccination:
Vaccination is the administration of a vaccine to help the immune system develop protection from a disease. It is the use of vaccines to prevent specific diseases.
In the study, it refers to administration of combination of Diphtheria, Pertussis, Tetanus, Hepatitis B and Hib vaccines
Assumptions
The study assumes that:
Facilitated tucking position may have an effect on level of pain perception among infants receiving Pentavalent vaccination.
Parents will cooperate and accepts new intervention.
Parents will give true information.
Tool measures accurately.
Delimitations
The study is delimited to:
Facilitated tucking position alone.
Pain perception during Pentavalent vaccination only.
12
Data collection done by the investigator alone.
Done in selected private Hospitals.
Conceptual Frame Work:
Chinn and Kramer (1999) defined a concept as a complex mental formulation of experience.
Miles and Huberman (1994) defines “Conceptual framework as a written or visual presentation that explains the main things to be studied in either graphically or narrative form-the key factors, concepts or the variables and the presumed relationship among them”
The present study was a true experimental study to assess the effectiveness of facilitated tucking position on level of pain perception during Pentavalent vaccination among the infant in selected OPD in Erode, Tamil Nadu. The conceptual framework for the present study is based on The Gate Control Theory of Pain which was proposed by Melzack and wall in 1965 who was the first one to recognize the psychological aspect of pain as important as physiological aspects.
The theory states that there are certain nerve fibres under our skin and tissues which are of small diameters that conduct excitatory pain stimuli towards brain, but nerve fibres of a large diameter appear to inhibit the transmission of pain impulses travelling from the spinal cord to the brain. There is a gating mechanism that located in substantia gelatinosa cells in the dorsal horn of the spinal cord. The site is thought to act as a gating that determines which impulse will be blocked and which will be transmitted to Thalamus. The image of gate is useful in teaching clients and their family about pain relief measures. If the gate is closed, the signals are stopped before
13
it reaches the brain, where the perception of pain occurs. If the gate is open the signal will continue on through the spinothalamic tract to the cortex and the client will feel pain. Whether the gate is closed or opened is influenced by impulses from peripheral nerves and nerve signals that descend from the brain. If a person is anxious, the gate can be opened by signals sent from the room down to the mechanism in the dorsal horn of the spinal cord. On the other hand if the person has had a positive experience with pain control in the past, the cognitive influence can send signals down to the gating mechanism and close it. The gate theory offered a great benefit by suggesting new approaches to relieving both acute and chronic pain. Pain could be relieved by blocking the transmission of pain impulses to the brain by both physical modalities and by altering the individual’s thought processes, emotions and behaviours.
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Stimulation of nerve Stimulus
Stimulation of pain receptors
Traveling of pain Pain gating Pain perception
mechanism
Infant variables
age
gender
gestational age
birth weight
birth order of the child
type of feeding
last feed given Maternal variables
educational status of mother
occupation of mother
area of living
nature of birth Clinical variables
previous history of medical illness
previous history of surgical illness
exposure to invasive procedure
Control group Stimulation of nerve endings
Traveling of pain through Small diameter fibres
Gate Open
Assessment of pain Neonatal Infant Pain Scale
(NIPS)
Experimental group
Gate Closed Super imposed
Severe pain
Moderate pain
Mild pain
No pain Travelling of pain
through large diameter
fibres
Fig. 1 Conceptual framework based on Pain Gate Control Theory (1965) on effectiveness of Facilitated Tucking position on level of pain perception
15
SUMMARY
This chapter consist of introduction, background of the study, needs of the study, problem statement, objective, hypothesis, operational definition, assumptions, delimitation conceptual framework and summary.
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CHAPTER - II
REVIEW OF LITERATURE
Literature review refers to the activities involved in searching for information on a topic and developing a comprehensive picture of the state as knowledge on that topic Hungler (2014).
This term is also used to designate a written summary of the state of art on a research problem. It is useful for consumers of nursing research to acquire skills for reading, critiquing, and preparing written evidence summaries. The investigator carried out extensive review of literature on the research topic in order to gain deeper insight into the problem as well as to collect maximum relevant information for building up the study. The literatures were collected from various sources like Indian and International journals, Pub med, Google Scholar, Research Gate and Thesis
The review of literature in the present study is organized as follows Section A: Studies related to Pain Perception among Infants.
Section B: Studies related Facilitated Tucking Position on Pain among Infants.
Section A:
Studies related to Pain Perception among Infants.Effect of the lavender oil inhalation on the pain resulting from the Pentavalent vaccination was conducted by Vaziri F et.al (2019. The study consisted of two groups: the lavender oil group with 42 infants and the placebo group with 57 infants. The healthy infants who did not have congenital abnormalities and needed Pentavalent vaccine also participated in this study. The infants started the lavender oil or placebo aromatherapy one minute before administration of the Pentavalent vaccine. The pain was assessed three times, using the Neonatal Infant pain Scale (NIPS): before vaccination, 15 seconds, and 5
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minutes after vaccination. The duration of crying was measured in both groups. The two groups were similar in relation to the NIPS scores, while after 5 minutes, the NIPS score was significantly lower in the lavender group. The results of the two groups were significantly different in relation to the NIPS score over time. The duration of crying was 75.47 (60.675) second in the lavender group and 105.22 (75.739) seconds in the control group. The statistical test showed a significant difference between the two groups. A low concentration of the lavender oil inhalation can reduce the pain and improve soothing in the infants with the Pentavalent vaccine injection.
Xiaomei Cong et. al. (2017) conducted a prospective exploratory study with fifty preterm infants (28–32 weeks of gestational age) recruited at birth and followed for four weeks. NICU Infant Stressor Scale was measured daily and NICU Network Neurobehavioral Scale was examined at 36–37 weeks post-menstrual age. Data analyses were conducted on the distribution of pain-stressors experienced over time and the linkages among pain-stressors and neurobehavioral outcomes. Preterm infants experienced a high degree of pain-stressors in the NICU, both in numbers of daily acute events (22.97 ± 2.30 procedures) and cumulative times of chronic-stressful exposure (42.59 ± 15.02 h). Both acute and chronic pain-stress experienced during early life significantly contributed to the neurobehavioral outcomes, particularly in stress-abstinence (p < 0.05) and habituation responses (p < 0.01), meanwhile, direct breastfeeding and skin- to-skin holding were also significantly associated with habituation (p < 0.01–0.05). The study concluded that understanding brain mechanisms by which early life experience alters neurodevelopment will assist clinicians in developing targeted Neuro protective strategies and individualized interventions to improve infant developmental outcome.
Hunseler C. Thangavelu K.Kribs A. Roth B. (2016) did a mixed-methods, prospective, open-label, single-arm, observational study in which routine capillary or
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peripheral blood takes were filmed. After a pilot evaluation, experienced medical and nursing neonatal intensive care unit (NICU) staff analysed the videos in which Twenty infants with gestational ages ranging from 22 weeks and 3 days to 26 weeks (mean 24 weeks) were recruited. Nineteen infants showed pain reactions, with a mean latency of 8.3 second (range 2-30). The majority presented eye movements, changes of the breath pattern and a slight increase in the mean SpO2 value. A high degree of interrater and intrarater reliability was found. This study concluded that premature infants with a gestational age of up to 26 weeks can present a variety of discrete reactions as response to a pain stimulus within the first 72 h of life. Experienced NICU staff can perform a valid and reliable evaluation of these reactions.
Esfahani MS, Sheykhi S, Abdeyazdan Z, Jodakee M, Boroumandfar K (2013) conducted a comparative study regarding the vaccination-related pain in infants who underwent massage therapy or breast feeding during injection. This study was a randomized clinical trial that comprised of Ninety-six infants who were allocated randomly and systematically to three groups (breast feeding, massage, and control groups).
The study comprised of all infants, accompanied by their mothers, referring to one of the health centres in Isfahan for vaccination of hepatitis B and DPT at 6 months of age and for Measles, Mumps, and Rubella at 12 months of age. Data collection was done using questionnaire and checklist [neonatal infant pain scale (NIPS)]. Findings of the study showed that the three groups had no statistically significant difference in terms of demographic characteristics (P > 0/05). The mean pain scores in the breast feeding group, massage therapy, and control group were 3.4, 3.9, and 4.8, respectively (P < 0.05). Then the least significant difference (LSD) post hoc test was performed. Differences between the groups, i.e. massage therapy and breast feeding (P = 0.041), breast feeding group and
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control (P < 0.001), and massage therapy and control groups (P = 0.002) were statistically significant. The study concluded that breast feeding during vaccination has more analgesic effect than massage therapy. Therefore, it is suggested as a non-invasive, safe, and accessible method without any side effects for reducing vaccination-related pain.
Eloisa Gitto et. al. (2012) evaluated the reduction of procedural pain induced by
“heel-lances” in preterm newborns with three different treatments [administration of fentanyl (FE, 1–2 μg/kg), facilitated tucking (FT), and sensorial saturation (SS)].
Secondary outcome was the measurement of the levels of cytokines as markers of stress correlated to pain. A prospective randomized controlled trial comparing three different pharmacological or non-pharmacological treatments was performed involving 150 preterm newborn (gestational age 27–32 weeks). CRIES score was used to evaluate the procedural pain. The results showed that the reduction in the pain score was greater in fentanyl administration and sensorial saturation groups than facilitated tucking group. The differences were statistically significant (p<0.01). The levels of IL-6, IL-8, and TNF-α were higher in the facilitated tucking individuals than in the fentanyl administration or sensorial saturation when treated at 1 day (p<0.01), at 3 days (p<0.01), and at 7 days (p<0.01) of life. The findings of this study suggest that fentanyl administration and saturation sensorial provide a superior analgesia in preterm neonates during procedural pain. In particular, sensorial saturation seems to be an important non-pharmacological alternative treatment to prevent and reduce the procedural pain in preterm newborn.
S. Karger AG, Basel (2007) compared physiological (heart rate, oxygen saturation) and behavioural (9 facial activities, cry) pain indicators of ELGA infants with infants of varying more mature gestational ages. Gestational age was categorized into four mutually exclusive strata: <27 weeks, 28–31 weeks, 32–35 weeks, and >36 weeks.
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Physiological data during four phases of a routine heel lance were collected by placing disposable ECG electrodes and pulse oximetry probes on the infant’s chest. Behavioural data were collected by videotaping facial activities, and cry data were collected by audio recording in which 4 facial activities (brow bulge, eye squeeze, nasolabial furrow, vertical mouth stretch) in response to acute pain were present in ELGA infants. Facial activities increased following painful procedures and the magnitude of responses was proportional to GA with the youngest infants (<27 weeks Gestational age) showing the least amount of change. Decreased oxygen saturation and increased heart rate were associated with the most invasive phase of the heel lance; however, the differences were neither clinically or statistically significant across age groups. Cry was not a sensitive pain indicator in ELGA infants, due to the presence of endotracheal tubes in this high-risk population. The study concluded that ELGA infants have similar pain responses to older infants, but the responses are dampened. Other factors such as severity of illness, frequency of painful procedures or medication use should be examined, as they may influence the pain responses in ELGA infants.
Bellieni C.V.et. al. (2003) measured Intracranial Pressure in 51 healthy newborns (gestational age: 35–41 weeks) during blood sampling, by means of a tonometer applied to the anterior fontanel. Peak Intracranial Pressure values were compared during 3 different types of blood sampling: from the external jugular vein (JV), by heel prick and by heel prick with sensorial saturation. Sensorial saturation consists in giving sensorial stimuli during pain to arrest the transmission of pain to the cerebral cortex. Intracranial Pressure peak values during heel prick were higher than during JV sampling (mean = 26.22 vs.
21.036 mm Hg; p < 0.0001), though babies who underwent the latter procedure had high ICP values before sampling due to the body position required. Heel prick with sensorial
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saturation was associated with a lower Intracranial Pressure peak (mean = 11.75 mm Hg) than sampling from JV (p < 0.0001). This study concluded that heel prick caused a greater rise in Intracranial Pressure than sampling from JV and that sensorial saturation moderated the rise associated with heel prick.
Moshe Ipp et. al (2009)determined the acute pain response after administration of the diphtheria, polio, and tetanus toxoids and acellular pertussis and Hemophilus influenzae type b vaccine and the pneumococcal conjugate vaccine is affected by the order in which they are given. Single-center, double-blind, randomized clinical trial was conducted at Outpatient paediatric clinic in Toronto, Ontario, Canada. Healthy infants with 2 to 6 months of age undergoing routine immunization were selected for the study population. Infants received either their primary Hemophilus influenzae type b vaccine or the PCV first, followed by the other vaccine. The primary outcome was infant pain during vaccine injection as assessed by a validated measure, the Modified Behavioural Pain Scale (MBPS), using videotaped recordings of the procedure. In addition, parents rated pain using a 10-cm visual analog scale (VAS). Crying (yes/no) was also measured. The study was conducted between July 21, 2006, and June 21, 2007. A total of 120 infants participated: 60 received the Hemophilus influenzae type b vaccine first and 60 received the PCV first. Infant characteristics did not differ between groups. Overall mean (SD) pain scores per infant after receiving both vaccine injections were significantly lower when Hemophilus influenzae type b was administered first compared with when PCV was administered first (MBPS score, 7.6 [1.5] vs. 8.2 [1.5], P = .037; parent VAS score, 4.2 [2.3] vs 5.6 [2.6], P = .003). When given first, the Hemophilus influenzae type b vaccine caused significantly less pain (P < .001) than the PCV, as assessed by the MBPS, VAS, and crying. Pain was reduced when the Hemophilus influenzae type b vaccine was administered before the PCV in infants undergoing routine vaccination. It was
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recommended that the order of vaccine injections be the Hemophilus influenzae type b vaccine followed by the PCV.
Amber L. Williams (2009) conducted a longitudinal study to evaluate the behavioural responses of 35 preterm newborns to multiple heel stick procedures during their stay in the NICU. Sixty-one video recordings of blood collection by heel lance were evaluated for behavioural pain response using the NIPS. Generalized linear mixed models were calculated to address the study objectives. The increases in NIPS scores from the baseline to the blood draw were highly significant (mean baseline score = 3.34, mean blood draw score = 5.45, p < 0.001). The newborns pain responses increased an average of 0.23 points on the NIPS scale each week (p = 0.002). Lower NIPS scores during the heel stick procedure were associated with four clinical variables: younger post-menstrual age at birth, lower birth weight, mechanical ventilation, and longer length of stay in the NICU.
Crying, arousal state, and facial grimace contributed more than 85% of the increase in NIPS scores during the heel stick procedure. The study concluded that while behavioural responses to pain are attenuated in young, severely ill preterm newborns, they can be reliably detected. The most strong pain behaviours are crying, changes in arousal state, and facial grimacing.
Gibbins S.et.al. (2008) compared the physiological and behavioural pain responses of infants at three levels of NI risk during the NICU neonatal period (Session 1) and at 6 months of age (Session 2). A prospective observational design with 149 preterm and term infants at high (Cohort A, n=54), moderate (Cohort B, n=45) and mild (Cohort C, n=50) risks for NI from 3 Canadian tertiary level NICUs. Infants were observed in the NICU during 3 standardized phases of a heel lance: baseline, stick and return-to-baseline. At 6 months, infants were observed during the same three phases during an intramuscular
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immunization injection. Physiological (heart rate, oxygen saturation) and behavioural (9 facial actions, cry) responses were continuously recorded. A significant interaction of Phase by Session was found with less total facial activity observed during Session 2 (all p values<0.04). A significant interaction for Session by Cohort was found, showing that infants in Cohort A had significantly more change from baseline-to-stick phase for brow bulge, eye squeeze, nasolabial furrow and open lips between sessions with less facial actions demonstrated at Session 2 (all p<0.02). There were significantly lower mean and minimum heart rate (all p<0.02) and higher minimum and maximum oxygen saturation (p<0.04) at Session 2. Significantly higher mean and minimum fundamental cry frequencies (pitch) in Cohort B (p<0.04) were found in Session 1. Cohort A had significantly longer cry durations, but no significant differences in cry dysphonation. The study concluded that behavioural and physiological infant pain responses were generally diminished at 6 months of age compared to those in the neonatal period with some differences between NI risk groups in cry responses. Future exploration into the explanation for these differences between sessions and cohorts is warranted.
Gonsalves S, and Mercer J (1993) investigated the physiological responses of preterm infants to procedures that are routinely performed in intensive care nurseries.
Changes in heart rate, respiration rate, and oxygen saturation were examined as indicators of the level of discomfort experienced by the infant during the procedures. Clinical descriptive Systematic observations of the infants were conducted during periods of rest as well as during routine interventions. All observations were recorded from monitored preterm infants in the intensive care units of two urban hospitals. Thirty-five preterm infants 24-30 weeks gestational age and weighing < 2,000 g at birth. Data were collected from all infants in the units who met the weight criterion. The researchers observed the
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infants while the intensive care nursery staffs were performing routine care procedures.
Observations were made during procedures that adults would consider to be painful, such as injection, heel stick, tape removal, and squeezing of the heel to induce blood flow after heel stick, as well as non-painful procedures, such as handling, temperature taking, alcohol swabbing, patting, taping a tube, feeding, and placing a pacifier. Heart rate, respiration rate, and oxygen saturation were recorded from infant monitors. Mean values of the three measures during procedures were compared with mean values before and after procedures.
Significant differences (p < 0.001) were found among pre-, peri and post-procedures for all three outcome measures. Heart rate and respiration rate means were significantly (p
<0.001) higher during procedures that adults consider to be painful than in those regarded as non-painful. Oxygen saturation was lower (p < 0.001) for painful procedures than for non-painful procedures. Gender and infant size comparisons yielded inconclusive results.
The outcome measures appear to be reliable indices of preterm infant responses to painful stimulation.
Section B:
Studies related to Facilitated Tucking Position on Pain among Infants.A study that aimed to investigate the effectiveness of facilitated tucking position on neonatal pain during heel prick blood sampling was done by Davari S, Borimnejad L, Khosravi S, Haghani H(2019). Cross over clinical trial was done on 40 premature neonates. During blood sampling, neonates were put in either facilitated tucking or routine positions randomly and Premature Infant Pain Profile (PIPP) was completed for each neonate. In the next sampling time, positions were changed and the process was repeated.
Data were analysed using descriptive statistics, repeated measure ANOVA, and independent t-test. Results showed that the mean pain intensity in each position was increased during sampling (p=.0001) and after that was decreased significantly (p=.001),
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but before, during, and after sampling there was no significant difference between the two positions (p>.05). Overall findings showed that comparing neonates in the two positions;
there was no significant difference in their pain intensity. These results are almost in contrast with many researches findings in this area. It seems there is a need to further investigation regarding this subject.
Prospective, randomized controlled trial study was done on Level III and II neonatal care units including the neurosensory care management program by Perroteau A.
et. al. (2018) that compared 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. 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 48hour 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 second before the procedure until three minutes after the end of the procedure. Pain was blindly assessed by two independent specialist nurses. The primary outcome was the pain score evaluated 15 second before the procedure and 30 second immediately after by the premature infant pain profile (PIPP) scale. The secondary outcome was the pain score evaluated between 15 second and 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: 6.0-12.0) and the control group (median: 9.5; interquartile range: 7.0-13.0, p = 0.32). Pain assessed by the
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DAN scale at 3 min was lower in the intervention group than in the control group (median:
0.3; interquartile range: 0.0-1.0 and 2.0; interquartile range: 0.5-3.0, respectively, p=
0.001).The study concluded that 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.
Leila Valizadeh et.al. (2018) aimed to determine the effects of facilitated fetal tucking on duration and frequency of crying among premature infants. This randomized, clinical trial was carried out in the Al-Zahra Hospital of Tabriz, Iran. 32 premature infants (33-36 weeks) were selected for the study. The initial selection of the participants was based on the simple random sampling. Then the participants were allocated to groups using randomized block procedure. Every infant was studied for 4 days in 12hours period every day (8 AM to 8 PM) in this sequential study infants were randomly assigned 2 days in free-body posture and 2 days in facilitated fetal tucking posture. Films recorded in the 12 hour periods. The mean of crying time for facilitated fetal tucking group was 17.50 minutes and at the free body posture was 23.35 minutes. The frequencies of crying in facilitated fetal tucking group were lower than free-body posture group. Also statistically significant difference was observed between durations of crying (p=0.009) and frequencies of crying (p=0.01). It is concluded that the fetal tucking posture reduces duration and frequency of crying during rest times among infants born prematurely which leads to an improvement in sleep and waking cycles and reduces stress in premature infant.
Sneha V. et.al (2018) aimed to assess the pain response during vein puncture in control group and effectiveness of facilitated tucking in reducing the pain response during vein puncture among preterm neonate admitted in Neonatal Intensive Care Unit and
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postnatal ward in experimental group at Krishna Hospital and Medical Research Centre, Karad, Maharashtra, India. The study design was post-test only control group design.30 preterm neonates in experimental group with facilitated tucking and 30 with routine NICU method in control group were the sample selected by non-probability purposive sampling technique. The result shows that the mean pain scores of experimental group was 2.47 and control group was 6.17. The unpaired t-test value was 20.76, (p<0.001) showing a significant difference between mean pain level of neonates for control and experimental group as p value <0.05. The study concluded that the facilitated tucking is a non- pharmacological, effective, simple, inexpensive and safe pain management technique for reduction in pain during the vein puncture procedure.
Gautheyrou L. et.al (2018) assessed the effect of facilitated tucking (FT) on echocardiographic parameters and infant comfort collected prospectively during neonatologist-performed echocardiography. It was performed twice, in standard conditions and with FT; the order was randomised by computer. Echocardiography provided data on pulmonary artery flow and pressure, right and left ventricular function, and persistent ductus arteriosus. Comfort was assessed by a behavioural scale of pain, variations in heart rate (HR) and SpO2 , and a newborn infant parasympathetic evaluation index based on the high-frequency variability in HR. Fifty newborns, with mean gestational age of 28 [26.6- 29.0] weeks and mean birth weight of 950 [780-1190] g, were studied at a postnatal age of 13 [9-27] hours. FT was associated with longer acceleration time/right ventricular ejection time in the main pulmonary artery (p = 0.006), reduced averaged HR variations (p = 0.03) and lower pain scores (p < 0.001). The other hemodynamic parameters and the parasympathetic index were not influenced by Facilitated tucking..
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Sujatha S, Samson, Amalraj, Sundaresan (2017) conducted a study with an objective to assess the efficacy of 24%oral sucrose in combination with facilitated tucking during BCG vaccination through intradermal route in neonates. Fifty five healthy term neonates who fulfilled the inclusion criteria such as gestational age above 37 weeks, within 24 hours of birth age, and neonates delivered only through spontaneous vaginal delivery were included in the study. The study intervention consists of administration of 2 ml of oral 24% sucrose 2 minutes before BCG Vaccination through intradermal route and Facilitated tucking at the time of vaccination. The primary outcome measure of cumulative NIPS score at 0, 3,5 minutes was not significant in both the study groups. Whereas there was significant reduction in the level of pain and mean cry time in the neonates of sucrose group. Heart rate and oxygen saturation after intradermal injection also showed significant (p < 0.001) difference among the neonates, who received 24% of oral sucrose& facilitated tucking than for neonates of control group. Thus oral (24%) sucrose solution given 2 minutes before injection was effective in reducing level of neonatal pain following intradermal vaccination. It is a simple, safe and fast acting analgesic and can be considered for minor invasive procedures in term neonates which last for 5-7minutes.
A randomized clinical trial study was conducted in neonatal ward of Al-Zahra Teaching Hospital of Tabriz, Iran was done by Valizadeh L, Ghahremani G, Gharehbaghi MM, Jafarabadi MA(2015) to compare the daily sleep quantities of premature infants in facilitated fetal tucking posture and extended free body posture. 32 premature infants with the age range of 33-36 weeks were selected for the study. Every infant was studied for 4 days in a sequential format in a 12 hour period every day (8 am-8 pm.). Each day, an infant was randomly put in one of the four statuses, namely, free body posture in the supine position, free body posture in the lateral position, facilitated fetal tucking in the supine position and facilitated fetal tucking in the lateral position. Films
