REDUCING PAIN USING FACILITATED TUCKING 1

Reducing Procedural Pain in Newborn Preterm Infants Using Facilitated Tucking

Danielle K. Johnson

College of Nursing, University of South Florida

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Abstract

Clinical Problem: Preterm infants in the neonatal intensive care unit (NICU) setting are subject

to an array of procedures and tests that inflict discomfort and even pain, leading to damaging

effects on infants’ ability to learn and remember things in the future.

Objective: This synthesis aims to examine the efficacy of using the facilitated tucking method to

reduce the pain experienced by preterm infants in the NICU. PubMed was used to find

randomized control trials (RCTs) about the use of facilitating tucking on preterm infants. The key

terms used in the search were preterm, NICU, procedural pain, and facilitated tucking.

Results: In newborn preterm infants facilitated tucking performed during painful procedures is an

effective method of decreasing the perception of pain over the duration of the procedure. Three

out of four of the RCTs showed that there was a decrease in the procedural pain of preterm

patients in the NICU when facilitated tucking is used during procedures. One RCT showed that

there was no substantial difference in the pain scores with or without facilitated tucking, but it

showed that when using both non-nutritive sucking and facilitated tucking, there was faster

recovery from pain post-procedure.

Conclusion: Facilitated tucking has been observed to have beneficial effects on the amount of

pain experienced by preterm infants during procedures in the NICU. Further research should be

conducted with the use of facilitated tucking alone as the method of pain management, as

opposed to facilitated tucking being used in combination with another pain management method.
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Reducing Procedural Pain in Newborn Preterm Infants Using Facilitated Tucking

A preterm infant in the NICU will be subject to many different diagnostics and

procedures with the goal of getting them healthy enough for discharge. Unfortunately, many of

these tests and procedures can cause discomfort or even pain (Perroteau et al., 2018). This pain

can lead to damaging effects on an infant’s ability to learn and remember things in the future

(Alinejad-Naeini et al., 2014). Therefore, facilitated tucking may reduce procedural pain in

preterm infants. In newborn preterm infants how effective is facilitated tucking performed during

painful procedures compared to other/no intervention in reducing pain over the duration of the

procedure?

Literature Search

PubMed was used to find randomized control trials (RCTs) about the use of facilitating

tucking on preterm infants. The key terms used in the search were preterm, NICU, procedural

pain, and facilitated tucking. The search results were limited to within the last 10 years.

Literature Review

Four RCTs were used to determine how effective facilitated tucking is to reduce

procedural pain among preterm infants in the NICU. In a randomized control trial, Alinejad-

Naeini et al (2014) assessed the pain of premature neonates receiving suctioning, with or without

the use of facilitated tucking. The assessment of heart rate, oxygen saturation, and facial actions

was used to measure pain. The sample size was 34 preterm infants between the age of 29 to 37

weeks of age. There was a randomized intervention group (n= 17) and a control group (n= 17).

Infants in the intervention group were exposed to endotracheal suctioning when held in a tucked

position, they were examined through a pulse oximeter and monitor. The infants were observed

over a period of 30 seconds. Further assessment of pain was collected using the Premature Infant
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Pain Profile (PIPP) tool. This study occurred over the course of five months. The author reported

that there was a substantial difference in the score of pain between cases (p<0.001), and the mean

pain score was significantly lessened in instances with intervention. Strengths of this study

include randomization of assignment, follow-up assessments were done promptly, an appropriate

control group was used, the scales used to analyze were valid, and the participants of similar

demographics and baseline clinical variables were used. Weaknesses of this study include the

assignments not being hidden from those who were enrolling participants, reasons as to why an

infant did not complete the study were not given, and participants and providers were not blind

to the group assignments.

On the other hand, Lopez et al. (2015) evaluated preterm infants’ pain during

venipuncture, with or without the use of facilitated tucking. The assessment of heart rate, crying,

sleep, and sleep-state changes was used to measure pain. The sample size was 42 preterm infants

at ages between 23 to 36 weeks of gestational age. There was a randomized intervention group

(n= 21) and a control group (n= 21). The intervention group was exposed to venipuncture when

held in a tucked position, their reactions were examined through video recording and a monitor.

The time needed for observing the infant was 15 seconds before the procedure to 30 seconds after

the procedure. Further assessment of pain was collected using the PIPP tool. This study was

conducted over the course of 16 weeks. The author reported that the PIPP score result of using

facilitated tucking in the intervention group was substantially lower than that of the control group

during venipuncture (p<0.005). Strengths of this study include randomization of assignment, the

reasoning was provided for those infants that did not complete the study, follow-up assessments

were done promptly, an appropriate control group was used, the scales used to analyze were

valid, and the participants were of similar demographics and baseline clinical variables. The
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weaknesses of this study were that the assignments were not hidden from those enrolling

participants and the participants and providers were not blind to the group assignments.

The study by Perroteau et al. (2018) compared the use of non-nutritive sucking alone to

the use of non-nutritive sucking in combination with facilitated tucking to diminish the pain of

preterm infants during heel-stick procedures. The assessment of heart rate, oxygen saturation,

limb movement, vocal expression, and facial actions were used to measure pain. The sample size

was 59 preterm infants at ages between 28 and 32 weeks of gestational age. The patients were

randomized into an intervention group (n= 30), or a control group (n= 29). The intervention

group was exposed to venipuncture when held in a tucked position with non-nutritive sucking,

their values were observed through a pulse oximeter and video recording. Infants were observed

from 15 seconds before the procedure to 30 seconds after the procedure. Further assessment of

pain was collected using the PIPP tool and the DAN scale. This study was conducted over the

course of 17 months. The author reported that there were no distinct differences between the pain

scores of the intervention group in comparison to the scores of the control group. However, when

using the DAN scale to assess pain 3 minutes post-heel-stick, the score was higher in the control

group than in the intervention group (p = 0.001). Strengths of this study include randomization of

assignment, infants that did not complete the study had a reason that was explained, follow-up

assessments were done promptly, an appropriate control group was used, the instruments used to

analyze were valid, and the participants were of similar demographics and baseline clinical

variables. The weaknesses of this study were that the assignments were not hidden from those

who were enrolling participants and participants and providers were aware of the group

assignments.
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Lastly, Ranjbar et al. (2020) compared the use of oral dextrose to the use of facilitated

tucking as a pain reduction method during heel-stick procedures on premature infants. The

assessment of heart rate, oxygen saturation, and facial actions was used to measure pain. The

sample size was 60 preterm infants at ages between 28 to 36 weeks of gestational age. The

patients were randomized into two intervention groups, one held in tucked position (n= 20) and

the other offered oral glucose (n=20), or a control group (n= 20). The first intervention group

was exposed to venipuncture when held in a tucked position and the second intervention group

was exposed to venipuncture two minutes after being offered oral dextrose by mouth. The time

needed for observing the infant was up to 30 seconds after the procedure. Further assessment of

pain was collected using the PIPP tool. This study was conducted over the course of 18 months.

The author reported that the PIPP score results were lower when using oral dextrose compared to

facilitated tucking, but both were lower than heel-stick procedures without pain control methods

(p<0.001). Strengths of this study include randomization of assignment, the reason why an infant

did not complete the study was provided, follow-up assessments were done promptly, the control

group was appropriate, the instruments used to analyze were valid, and the participants were of

similar demographics and baseline clinical variables. The weaknesses of this study were that the

assignments were not hidden from those who were enrolling the participants and the participants

and providers were aware of the group assignments.

Synthesis

Data from the Alinejad-Naeini et al (2014) trial revealed that the infants in the

intervention group experienced less pain when being held in the facilitated tucking method

(p<0.001). Similarly, Lopez et al. (2015) showed that there was a significantly lower pain score

in patients held in a facilitated tucking position during procedures than those in the control group
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(p<0.005). Likewise, Ranjbar et al. (2020) demonstrated a lower pain score during heel-stick

procedures when held in the facilitated tucking position. On the contrary, Perroteau et al. (2018)

did not show a substantial difference in the procedural pain scores between the intervention and

control groups, but it did show there was a quicker recovery from pain in infants in the

intervention group.

There should be a larger amount of RCTs that have tested how well the facilitated tucking

method works in relieving the pain of preterm infants in the NICU. Many of the studies found

had more than one intervention group. Testing the efficacy of facilitated tucking alone could

provide more significant evidence of its effectiveness.

Clinical Recommendation

Evidence suggests that facilitated tucking can be used as an effective pain control method

for preterm infants. The Premature Infant Pain Profile (PIPP) tool and Douleur Aiguë Nouveau-

né (DAN) scales were used to determine the effectiveness of this practice in the clinical setting.

Increasing the use of this practice by teaching the facilitated tucking method to NICU nurses and

providers could lead to an overall decrease in the pain experienced by preterm infants during

their hospital stays. By decreasing the pain these infants are experiencing there will also be a

decrease in the negative effects associated with the pain. This includes the effect pain has on

infants' ability to learn and remember things in the future.

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References

Alinejad-Naeini M, Mohagheghi P, Peyrovi H, Mehran A. The effect of facilitated tucking during

endotracheal suctioning on procedural pain in preterm neonates: a randomized controlled

crossover study. Glob J Health Sci. 2014 May 4;6(4):278-84.

http://doi.org/10.5539/gjhs.v6n4p278

Lopez, O., Subramanian, P., Rahmat, N., Theam, L.C., Chinna, K. and Rosli, R. (2015), The

effect of facilitated tucking on procedural pain control among premature babies. J Clin

Nurs, 24: 183-191.

https://doi.org/10.1111/jocn.12657

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

Efficacy of facilitated tucking combined with non-nutritive sucking on very preterm

infants' pain during the heel-stick procedure: A randomized controlled trial. Int J Nurs

Stud. 2018 Oct;86:29-35.

https://doi.org/10.1016/j.ijnurstu.2018.06.007

Ranjbar, A., Bernstein, C., Shariat, M. et al. Comparison of facilitated tucking and oral dextrose

in reducing the pain of heel stick in preterm infants: a randomized clinical trial. BMC

Pediatr 20, 162 (2020).

https://doi.org/10.1186/s12887-020-2020-7