Maternal contact in the skin-to-skin paradigm of KMC decreases pain response in preterm neonates between 28–32 weeks gestational age who are undergoing a heel lance for blood procurement, although the magnitude of the difference is less than 2 points on the 21-point outcome measure, found in our report of infants 32–36 weeks [34
]. The differences between incubator and KMC were approximately between 1.1 and 1.8 in the first three 30 second blocks of time, out of a total possible score of 21. While the levels reached statistical significance for some of the phases, and the mean individual components of the PIPP reached statistical differences, the magnitude of the effect was smaller than estimated, based on our earlier study of 32–36 weeks gestational age infants [34
]. The effect of KMC was not immediate following the heel lance, as in the study with the older preterm neonates, but was evident further into the heel lance procedure, not until 90 seconds post lance. This delay in effect after the lance was curious since more infants were in quiet sleep during baseline in the KMC condition, and quiet sleep dampens pain response [59
]. It appears then, that while preterm neonates less than 32 weeks gestational age do have some endogenous mechanisms that can be invoked through maternal skin-to-skin contact, its effect is not as powerful and it is not as quickly activated as in older preterm neonates.
The issue of when to take baseline measures for the PIPP when the intervention begins many minutes before the heel lance procedure needs addressing. According to PIPP guidelines, baseline measures of state, heart rate and oxygen saturation levels are recorded just prior to the actual procedure, such as the heel lance. In studies such as this when the intervention occurs before the baseline measures would normally be recorded, the values of state, heart rate and oxygen saturation levels are not at baseline levels, because KMC has a modifying effect on each of these parameters. Future research with KMC should take baseline measures before putting the infant into KMC to reflect true baseline measures.
Perhaps more importantly, was the significantly quicker time to recovery. Of clinical interest on procedural pain in very preterm neonates are response, that is the degree to which they respond, and recovery, how quickly they return to pre-procedure state. The ability to recover quickly is a sign of ability to maintain homeostasis, a major task that the very preterm neonate must accomplish in order to grow and develop [60
]. Facilitation of homeostasis maintenance through KMC has been reported regarding temperature, state, oxygen saturation levels, and growth [62
] but not in the context of the additional stress of pain. The results of this study indicate that maternal contact can facilitate not only a diminished response, but a quicker recovery in infants between 28 and 32 weeks gestational age.
There are some explanations other than maternal contact for the results. It was impossible to blind the person conducting the heel lance procedure, so that they may have been gentler during that condition. Anecdotally however, they preferred the incubator condition since conducting the procedure in KMC meant the person procuring the blood sample had to bend over towards the infant or be seated on a stool next to mother and infant, not standing next to incubator. Additionally the mother would be observing and some staff were not comfortable with that. When the infant was in KMC, gravity may have helped the blood flow and made the procurement faster, although the 17 second difference was not significant.
Infants in this study were not intubated or even requiring supplemental oxygen, according to the protocols of the units at the time the study began. Now, some intubated infants are permitted to be in KMC and it would be interesting to see if KMC is efficacious for procedural pain in a similar age group, but intubated population. One study on KMC in neonates less than 28 weeks showed that those infants[71
] could not maintain temperature in KMC, and until other studies contradict that, studying KMC for pain control in infants less than 28 weeks may not be indicated at this time.
Kangaroo Mother Care for pain management in preterm neonates is obviously cost-effective and has now been shown to be effective in infants from 28 weeks through term. Mothers should be offered KMC as NICU policy, not only to be close to their infant, but also to provide comfort. It is not known if KMC is commonly included as a non-pharmacologic intervention for procedural pain in NICU's but based on results here as well as earlier studies with older preterm neonates, it would be recommended, alone or in conjunction with other strategies such as sweet solutions[6