Pain Management Nursing xxx (xxxx) xxx

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Pain Management Nursing

journal homepage: www.painmanagementnursing.org

Original Article

Effect of Kangaroo Care and Oral Sucrose on Pain in Premature Infants:

A Randomized Controlled Trial
Elif Sen, Msc *, Gulay Manav, PhD y
*
Health Sciences Institute, University of Uskudar, Istanbul, Turkey
y
Faculty of Health Sciences Department of Nursing, University of Uskudar, Istanbul, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Background: Premature infants hospitalized in the neonatal intensive care unit are routinely exposed to
Received 9 October 2019 many painful procedures. Pain experienced during the neonatal period may lead to negative outcomes,
Received in revised form especially in preterm neonates, hence pain in infants should be reduced. Kangaroo care and oral sucrose
28 April 2020
are some of the methods that can help reduce pain.
Accepted 19 May 2020
Aim: This study aimed to compare the effects of kangaroo care and oral sucrose on pain relief in preterm
infants during heel lancing.
Methods: Our study involved 64 infants. The infants were randomly divided into two groups using a
randomized block design of drawing out slips from a thick, non-transparent envelope. There were 64
slips in this envelope (32 for kangaroo care and 32 for oral sucrose). Kangaroo care was given to the
preterm infants in the first group and oral sucrose to those in the second group. In both groups, heart rate
and oxygen saturation were measured and pain score was evaluated by two observers using the Pre-
mature Infant Pain Profile (PIPP) before, during, and 2 minutes after blood sampling by heel lancing.
Results: There was a statistically significant difference between the groups in favor of the kangaroo group
in terms of change in the PIPP values after heel lancing. Kangaroo care is more effective than oral sucrose
in pain relief during heel lancing in preterm infants.
Conclusions: In addition to many benefits it offers to infants, kangaroo care can be used to reduce pain
during painful procedures in premature infants.
© 2020 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

According to the World Health Organization (WHO), around 15 In the past, it was thought that neonatal preterm infants’ ner-
million premature infants are born worldwide every year (Gao et al., vous systems were not developed sufficiently, hence they had dif-
2015). Most of these preterm infants are admitted to a neonatal ficulty in perceiving pain, and when they perceived it, the
intensive care unit (NICU) according to their gestational age and interpretation would be inadequate (Dinçer et al., 2011: Holsti et al.,
clinical condition, and are exposed to many painful procedures 2005). Studies on pain have shown that anatomical, neurophysio-
during their stay (Chidambaram et al., 2014; Derebent & Yig
it, logical, and hormonal development necessary for the fetus to
2006). According to Simons et al. (2003), approximately 14 painful perceive pain during late pregnancy is achieved and that the pain
procedures are performed on preterm infants born at 25-42 weeks experienced can have adverse effects (Anand & Hickey, 1987).
gestational age in the first 14 days of life. Some of these procedures Persistent or recurrent pain in newborn preterm infants affects all
and examinations include heel lancing, venipuncture or arterial their organs and systems, affects brain development, and causes
puncture, intramuscular/subcutaneous injection, percutaneous serious morbidity and even mortality (Valeri et al., 2015; Vinall
central venous catheter insertion, tracheal intubation, chest tube et al., 2012). Pain relief in neonates is therefore critically impor-
insertion, lumbar puncture, and retinopathy examination (Alinejad- tant. Pain experienced during the neonatal period may lead to
Naeini et al., 2014). negative outcomes, especially in preterm neonates. Nurses can be
very instrumental in managing pain-relieving practices (pharma-
cological/non-pharmacological) in neonates.
Although medical procedures are known to be painful in the
Address correspondence to Elif Sen, Msc, Yurtcan Street Number: 1 Altunizade
Acibadem Hospital, Uskudar, Istanbul, Turkey. neonatal period, pain management is limited and not frequently
E-mail address: nurelifsenn@gmail.com (E. Sen). used to alleviate pain (Ismail and Gandhi, 2011). Untreated

https://doi.org/10.1016/j.pmn.2020.05.003
1524-9042/© 2020 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

Please cite this article as: Sen, E., & Manav, G., Effect of Kangaroo Care and Oral Sucrose on Pain in Premature Infants: A Randomized Controlled
Trial, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2020.05.003
2 E. Sen, G. Manav / Pain Management Nursing xxx (xxxx) xxx

procedural pain in newborns can cause severe stress, develop- aspiration are effective in reducing pain in neonates (Wilson-Smith,
mental delay, and permanent neurological and emotional disor- 2011). These methods include kangaroo care, massage, playing
ders (Ghoneim, 2016). Proper pain relief is an ethical requirement music, pacifier, wrapping, nesting, prone position, rocking maternal
and necessary to improve the short- and long-term prognosis of touch, maternal sound and odor, breastfeeding and fetal position,
the infants (Chidambaram et al., 2014; Derebent & Yig
it, 2006). reducing environmental stimulation, and individualized develop-
Nurses play an important role in pain reduction and should be able mental care (Derebent & Yig
it, 2008).
to recognize pain, provide effective treatment, monitor the The use of sucrose is common because it is easily available, easy
outcome of treatment, and help reduce pain using non- to administer, and inexpensive (Dinçer et al., 2011). Clinical studies
pharmacological pain-relief methods (Golianu et al., 2007). have shown that oral sucrose reduces pain when used in
Pharmacological and nonpharmacological methods are used to conjunction with a pacifier (Elsefary et al., 2009). However, sucrose
reduce pain in infants. There are several pharmacologic approaches has some negative effects: hyperglycemia, fluid overload, necro-
to pain management, including topicals, acetaminophen, tizing enterocolitis, and neuromotor growth retardation may be
nonsteroidal/anti-inflammatory agents, opiates, and deep sedation observed with frequent use of sweet solutions in large amounts
or general anesthesia (Allagaert et al., 2013; Hall, 2012; Johston (Johnston et al., 1999; Yig
it et al., 2018).
et al., 2011; Potts & Mandleco, 2002). Kangaroo care, also called skin-to-skin contact, is a method that
It is reported that pharmacological methods that are used to can be easily performed and does not require any additional prep-
alleviate pain in newborns have some side effects, such as respi- aration. Kangaroo care also has the following benefits: stabilizing
ratory depression, apnea, bradycardia, hypotension, desaturation, newborn's vital signs, developing the nervous system, encouraging
partial airway obstruction, and hypersalivation (Lago et al., 2009). early feeding, reduced crying, early discharge from the hospital,
In addition, intravenous morphine infusion does not result in reduced morbidity as a result of reduced cross-infection, and deeper
adequate analgesic effect in preterm newborns during invasive and better-quality sleep. In addition, it has an important place in the
procedures (Hall & Anand, 2014). Pharmacological methods should care and treatment of newborns because it increases the bond be-
be enhanced through the use of nonpharmacological methods. tween the mother and baby (Kostandy et al., 2008).
Such methods are valuable alternatives for pain control when The side effects of sucrose and similar sweet solutions indicate
minimally invasive procedures are performed on newborn infants the need for nonpharmacological analgesia options such as kan-
(Maciel et al., 2019). garoo care, especially in preterm neonates. The aim of this study
It has been found that nonpharmacological methods applied was to compare the effects of kangaroo care and oral sucrose on
during painful procedures such as heel lancing and repeated pain during heel lancing in preterm neonates.

it et al., 2018).

Figure 1. Oral sucrose administration form (Yig

Please cite this article as: Sen, E., & Manav, G., Effect of Kangaroo Care and Oral Sucrose on Pain in Premature Infants: A Randomized Controlled
Trial, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2020.05.003
 E. Sen, G. Manav / Pain Management Nursing xxx (xxxx) xxx 3

Figure 2. Research flow diagram. HR ¼ heart rate; PIPP ¼ Premature Infant Pain Profile.

Table 1
Comparison of Descriptive Characteristics Between Groups

Kangaroo Oral Sucrose Test Value p

Gender
*
Female 18 (56.3) 14 (43.7) 1.000 .317
Male 14 (43.7) 18 (56.3)
Gestational week
Mean ± SD 34.38 ± 1.59 34.95 ± 1.43 1.486 y.142
Postnatal age (day)
Mean ± SD 8.31 ± 2.97 7.37 ± 2.39 1.391 y.169
Birth weight
Mean ± SD 2102.97 ± 346.21 2244.69 ± 344.89 1.640 y.106
Type of birth
C/S 30 (93.7) 30 (93.7) 0.000 z.999
Vaginally 2 (6.3) 2 (6.3)
Diagnosis
Prematurity 21 (65.6) 23 (71.9) 4.899 x.092
Prematurity þ RDS 9 (28.1) 3 (9.4)
Prematurity þ TTN 2 (6.3) 6 (18.7)

C/S ¼ cesarean/section; RDS ¼ respiratory distress syndrome; SD ¼ standard deviation; TTN ¼ transient tachypnea of the newborn.
*
Pearson c2 test.
y
Independent groups t test.
z
Fisher exact test.
x
Fisher-Freeman-Halton exact test.

Please cite this article as: Sen, E., & Manav, G., Effect of Kangaroo Care and Oral Sucrose on Pain in Premature Infants: A Randomized Controlled
Trial, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2020.05.003
4 E. Sen, G. Manav / Pain Management Nursing xxx (xxxx) xxx

Table 2 5. Infants with grade 3 or 4 intraventricular hemorrhage

Determining the Level of Concordance Between the Two Observers in Terms of PIPP
Assessments
The pain score was calculated using the Premature Infant Pain
Gwet's AC (95% CI) p Profile (PIPP) before, during, and 2 minutes after blood sample
PIPP Before HL 0.910 (0.832-0.988) <.001* collection in both patient groups. Heart rate (HR) and oxygen satu-
PIPP During HL 0.651 (0.515-0.786) <.001* ration percentage (SpO2) were measured in both patient groups
PIPP After HL 0.822 (0.718-0.926) <.001* before, during, and 2 minutes after blood sampling. The flow dia-
AC ¼ agreement coefficient; CI ¼ confidence interval; HL ¼ heel lancing. gram of our study is shown in Figure 2.
*
p < .01. The PIPP was developed by Stevens et al. in 1996, and subse-
quently revised and validated for use with preterm babies born at
26-37 weeks of gestation by Gibbins et al. in 2014. In the PIPP,
Material and Methods gestational age, behavioral status, highest heart rate value, lowest
oxygen saturation value, brow bulge, eyes squeeze, and nasolabial
This prospective randomized controlled trial involved preterm furrow are observed to evaluate the neonate's pain level. Each item
neonates hospitalized in a level-3 NICU in a metropolitan hospital is scored 0 to 3, from low to high (Stevens, Johnston, Petryshen, &
between April 2019 and August 2019. A total of 64 premature in- Taddio, 1996). The infant's pain level is determined on the basis of
fants born between 32 and 37 weeks were included in the study. All the total score, where the highest score is 21 and the lowest score is
infants were hospitalized in the intensive care unit. The infants 0. If the PIPP score is 0-6 points, the pain is considered mild; 7-12
were divided into two groups using a randomized block design points, moderate; and 13-21 points, severe.
method of drawing out slips from a thick, nontransparent envelope.
There were 64 slips in the envelope: 32 for kangaroo care and 32 for Ethical Approval
oral sucrose. Accordingly, 32 neonates were placed in the kangaroo
care group and 32 in the oral sucrose group. In our study, data were Approval was obtained from the Medical Research Ethics Com-
collected by observation and recorded by two observers. In the mittee of the University on April 18, 2019 (2019-8/1). The parents of
kangaroo care group, kangaroo care was started 15 minutes before preterm neonates included in the study were informed about the
heel lancing to measure blood glucose levels. Care was performed study and informed consent was obtained from them.
using the kangaroo care procedure (Ghoneim, 2016). In the sucrose
group, 0.5 mL oral sucrose in 24% concentration (Fig. 1) was given to Statistical Analysis
the neonates without pacifier by the researcher 2 minutes before

it et al., 2018).
blood collection (Yig The Number Cruncher Statistical System (NCSS) 2007 (Kaysville,
Utah, USA) was used for statistical analysis. Descriptive statistical
methods (mean, standard deviation, median, first quarter, third
Inclusion Criteria
quarter, frequency, percentage, minimum, maximum) were used to
evaluate the study data. The suitability of quantitative data for
1. Infants aged between 0 and 28 days of life
normal distribution was tested by the Shapiro-Wilk test and
2. Infants born between 32 and 37 gestational weeks
graphical analysis. Independent groups t test was used for com-
3. Weight less than 2500 grams
parison of two groups of quantitative variables showing normal
4. Hemodynamically stable
distribution, and Mann-Whitney U test was used for comparison
5. To be fed at least 1 hour before the procedure
between two groups of quantitative variables that did not show
normal distribution. Dependent groups t test was used for intra-
group comparisons of quantitative variables showing normal dis-
Exclusion Criteria tribution. Wilcoxon signed-ranks test was used for intragroup
comparisons of quantitative variables that were not normally
1. Infants on mechanical ventilator support distributed. Pearson's c2 test, Fisher's Exact test, and Fisher-
2. Infants who received sedative or analgesia within the last Freeman-Halton Exact test were used to compare the quantitative
72 hours data. Gwet's AC and intraclass correlation coefficient were used to
3. Infants with major congenital anomaly determine interobserver compatibility. A p value less than .05 was
4. Hemodynamically unstable considered significant.

Table 3
Determining the Level of Concordance Between the Two Observers in Terms of HR Values

HR O1 O2 ICC (95% CI) p

Before HL
Min-Max (Median) 110-151 (136) 112-155 (136) 0.992 (0.987-0.995) <.001*
Mean ± SD 134.98 ± 9.94 135.13 ± 9.37
During HL
Min-Max (Median) 124-185 (151.5) 128-184 (151.5) 0.986 (0.976-0.992) <.001*
Mean ± SD 152.08 ± 11.24 151.56 ± 10.7
After HL
Min-Max (Median) 109-159 (139) 110-159 (139) 0.986 (0.977-0.991) <.001*
Mean ± SD 138.73 ± 10.57 138.92 ± 9.79

O1 ¼ observer1; O2 ¼ observer2; ICC ¼ intraclass correlation coefficient; CI ¼ confidence interval; HL ¼ heel lancing; HR ¼ heart rate; Min ¼ minimum; Max ¼ maximum;
SD ¼ standard deviation.
*
p < .01.

Please cite this article as: Sen, E., & Manav, G., Effect of Kangaroo Care and Oral Sucrose on Pain in Premature Infants: A Randomized Controlled
Trial, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2020.05.003
 E. Sen, G. Manav / Pain Management Nursing xxx (xxxx) xxx 5

Table 4
Determining the Level of Concordance Between the Two Observers in Terms of SpO2 Values

SpO2 O1 O2 ICC (95% CI) p

Before HL
Min-Max (Median) 94-100 (98) 94-100 (98) 0.988 (0.979-0.993) <.001*
Mean ± SD 98.08 ± 1.62 98.14 ± 1.57
During HL
Min-Max (Median) 85-100 (97) 87-100 (97) 0.975 (0.959-0.985) <.001*
Mean ± SD 96.5 ± 2.74 96.53 ± 2.49
After HL
Min-Max (Median) 94-100 (98) 94-100 (99) 0.972 (0.971-0.991) <.001*
Mean ± SD 98.28 ± 1.47 98.34 ± 1.49

O1 ¼ observer1; O2 ¼ observer2; ICC ¼ intraclass correlation coefficient; CI ¼ confidence interval; HL ¼ heel lancing; Min ¼ minimum; Max ¼ maximum; SD ¼ standard
deviation; SpO2 ¼ oxygen saturation.
*
p < .01.

Results the change in PIPP values during and after heel lancing (p ¼ .002)
between the oral sucrose and kangaroo care groups, indicating the
The study was conducted between April 2019 and August 2019 superiority of kangaroo care.
in a 23-bed, level 3 NICU involving 64 neonates; 50% (n ¼ 32) of the The mean values and changes observed over time in HR and
study population consisted of females. The comparison of the SpO2 values in the sucrose and kangaroo groups are shown in
descriptive characteristics of the patients is shown in Table 1. There Tables 6 and 7 and Figures 4 and 5, respectively. Accordingly, there
was no statistically significant difference in the descriptive char- was a statistically significant difference between the groups in
acteristics of the infants in the kangaroo and sucrose groups terms of the changes observed in HR values after and before heel
(p > .05). lancing (p < .001); the change observed in the oral sucrose group
The PIPP scores and HR and SpO2 values, as recorded by two was greater than that in the kangaroo care group. There was no
observers, for the kangaroo and sucrose groups are shown in statistically significant difference between the groups in terms of
Tables 2e4. The level of concordance between the two observers changes in SpO2 values after and during heel lancing (p > .05).
was found to be high.
Pain scores and changes in pain scores before, during, and after Discussion
heel lancing between the groups are shown in Figure 3 and Table 5.
The change in PIPP values after heel lancing was statistically sig- Many invasive procedures are performed on newborns in the
nificant in both the kangaroo group and sucrose group as compared NICU, and heel lancing is the most common. These interventions
to during heel lancing (p < .001). The PIPP values were lower in the lead to pain in infants, and this pain has some negative effects on
kangaroo group than in the sucrose group 2 minutes after heel infants (Cong et al., 2012). Using appropriate pain scales and
lancing (p < .001). There was a statistically significant difference in minimizing or preventing pain in neonates can help improve their

Figure 3. Variation of PIPP values in groups and over time. HL ¼ heel lancing; PIPP ¼ Premature Infant Pain Profile.

Please cite this article as: Sen, E., & Manav, G., Effect of Kangaroo Care and Oral Sucrose on Pain in Premature Infants: A Randomized Controlled
Trial, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2020.05.003
6 E. Sen, G. Manav / Pain Management Nursing xxx (xxxx) xxx

Table 5
Investigation of Observed Changes in PIPP Values in Groups and Over Time

PIPP Kangaroo Oral Sucrose Test Value p*

Median (Q1, Q3) Median (Q1, Q3)

Before HL 4 (4, 5) 5 (4, 5) 1.591 .112

During HL 7 (6, 8) 7 (7, 8) 0.627 .531
After HL 3 (3, 4) 4 (4, 5) 3.567 <.001z

Change Median (Q1, Q3); py Median (Q1, Q3); py Test Value p*

During-before 3 (2, 4); p < .001z 3 (2, 4); p < .001z 0.504 .614
After-before 0 (1, 0); p ¼ .001z 0 (0, 1); p ¼ .432 2.959 .003z
After-during 4 (4, 3); p < .001z 3 (3, 2); p < .001z 3.084 .002z

Q1 ¼ first quarter; Q3 ¼ third quarter.

*
Mann-Whitney U test.
y
Wilcoxon signed-rank test.
z
p < .01.

health outcomes. Nurses working in the NICU have an important the PIPP scores of the kangaroo care group were found to be
duty in this regard. Nurses can use nonpharmacological methods to significantly lower than those of the control groups. In our
reduce pain (Mangat et al., 2018). In this study, we aimed to study, it was found that the change in PIPP values during and
compare the effectiveness of kangaroo care and oral sucrose, which after heel lancing was statistically significant in the kangaroo
are used to relieve pain during heel lancing, in reducing pain in group (p < .001). This shows that kangaroo care reduces pain
preterm neonates. during heel lancing.
In a crossover study conducted to determine the efficacy of Several studies have suggested that sucrose reduces pain in
kangaroo care in reducing heel lancing pain in preterm infants, preterm infants. Woodward, Pereira, and Dempsey (2008) found
it was found that kangaroo care was effective in reducing pain that 24% oral sucrose is an effective method for reducing pain in
in preterm infants (Chidambaram et al., 2013). A randomized infants. Yılmaz and Arıkan (2011) examined the effect of three
crossover study was conducted on the effects of kangaroo care nonpharmacological methods to reduce pain and crying time
on crying and pain in preterm infants. Preterm infants were during heel lancing. They divided the newborns into three
given kangaroo care on the first day and routine incubator care different groups: breast milk, sucrose, and pacifier. Among these
on the second day of a painful procedure; kangaroo care was three nonpharmacological methods, sucrose was found to be
found to be superior to incubator care (Konstandy et al., 2008). the most effective method in shortening crying time during heel
In a study involving 59 preterm infants, the effect of kangaroo lancing. In another study, 25% 0.5 mL/kg sucrose was given
care and standard care on pain relief during heel puncture was during minor painful procedures for 3 consecutive days, and
compared, and kangaroo care was found to be more effective in this treatment was found to be effective in reducing pain, with
reducing pain (Castral et al., 2008). In a prospective random- no side effects (Gaspardo et al., 2008). Acharya, Annamali, Taub,
ized crossover study involving 28 preterm infants, the effects of and Field (2004) reported that oral sucrose administered 2 mi-
kangaroo care and standard care on pain during heel puncture nutes before venous intervention reduced the pain score in
were compared, and lower pain scores were observed in the infants. By contrast, some studies have showed that sucrose has
kangaroo care group (Cong et al., 2011). In a study by Gray little effect on pain relief. Codipietro, Ceccarelli, and Ponzone
et al., the pain of preterm infants swaddled during an invasive (2008) found that infants who were breastfed during the heel
procedure and that of those receiving 10-15 minutes of kan- puncture had less pain than infants receiving sucrose. In a
garoo care were compared, and it was found that kangaroo randomized study conducted by Mathai, Natrajan, and
care significantly reduced pain (Gray et al., 2000). In another Rajalakshmi (2006) to compare nonpharmacological methods
study, Johnston et al. (2003) performed kangaroo care during for reducing pain during heel prick in 104 stable full-term ne-
the heel lancing of infants aged 32-36 gestational weeks, and onates, it was found that rocking or giving a pacifier was more

Table 6
Investigation of Observed Changes in HR Values in Groups and Over Time

HR Kangaroo Oral Sucrose Test Value p*

Mean ± SD Mean ± SD

Before HL 137.84 ± 9.03 132.13 ± 10.11 2.387 .020y

During HL 152.22 ± 8.79 151.94 ± 13.38 0.099 .921
After HL 137.00 ± 10.31 140.47 ± 10.71 1.320 .192

Change Mean ± SD; pz Mean ± SD; pz Test Value p*

During-After 14.38 ± 8.41; p < .001x 19.81 ± 8.63; p < .001x 2.553 .013y
After-Before 0.84 ± 8.20; p ¼ .565 8.34 ± 8.12; p < .001x 4.502 <.001x
After-During 15.22 ± 8.89; p < .001x 11.47 ± 7.82; p < .001x 1.791 .078
*
Independent groups t test.
y
p < .05.
z
Dependent groups t test.
x
p < .01.

Please cite this article as: Sen, E., & Manav, G., Effect of Kangaroo Care and Oral Sucrose on Pain in Premature Infants: A Randomized Controlled
Trial, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2020.05.003
 E. Sen, G. Manav / Pain Management Nursing xxx (xxxx) xxx 7

Table 7
Investigation of Observed Changes in SpO2 Values in Groups and Over Time

SpO2 Kangaroo Oral Sucrose Test Value p*

Mean ± SD Mean ± SD

Before HL 98.19 ± 1.69 97.97 ± 1.56 0.538 .592

During HL 96.69 ± 2.67 96.31 ± 2.84 0.544 .589
After HL 98.53 ± 1.41 98.03 ± 1.51 1.366 .177

Change Mean ± SD; py Mean ± SD; py Test Value p*

During-After 1.5 ± 1.88; p < .001x 1.66 ± 2.57; p ¼ .001x 0.277 .783
After-Before 0.34 ± 1.15; p ¼ .102z 0.06 ± 0.80; p ¼ .662 1.133 .261
After-During 1.84 ± 2.02; p < .001x 1.72 ± 2.49; p < .001x 0.221 .826
*
Independent groups t test.
y
Dependent groups t test.
z
p < .05.
x
p < .001.

effective than giving breast milk, distilled water, sucrose, or a pain control in preterm infants (Shukla et al., 2018). Lower pain
massage. In 2013, Bembich et al. examined the effect of scores were observed in the skin-to-skin contact group, but not
breastfeeding and sucrose administration on the brain during at a statistically significant level. Ghoneim (2016) compared the
painful procedures in infants (Bembich et al., 2013). They re- effects of oral sucrose administration and kangaroo care on pain
ported that breastfeeding stimulates the cortical activity of the relief in preterm newborns during painful procedures, and found
baby and reduces pain via various sensory experiences. In our that sucrose was superior to kangaroo care in reducing pain. He
study, we found that the change in PIPP values during and after recommended further studies to demonstrate the effect of kan-
heel lancing in the sucrose group was statistically significant garoo care on pain reduction. In our study, we found that there
(p < .001). We thus found that oral sucrose reduces the pain of was a statistically significant difference in favor of kangaroo care
heel lancing. in terms of the change in PIPP values during and after heel
Some studies compared the effect of kangaroo care and oral lancing (p ¼ .002). We thus concluded that kangaroo care is more
sucrose on reducing pain in newborns. In 2018, Shukla et al. effective in reducing pain undergoing heel lancing than oral
compared the effectiveness of sucrose and skin-to-skin contact in sucrose.

Figure 4. Change of HR values in groups and over time.

Please cite this article as: Sen, E., & Manav, G., Effect of Kangaroo Care and Oral Sucrose on Pain in Premature Infants: A Randomized Controlled
Trial, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2020.05.003
8 E. Sen, G. Manav / Pain Management Nursing xxx (xxxx) xxx

Figure 5. Change of SpO2 values in groups and over time.

Conclusion A cross-over trial. The Journal of Maternal-Fetal & Neonatal Medicine, 7(5),
488e489.
Codipietro, L., Ceccarelli, M., & Ponzone, A. (2008). Breastfeeding or oral sucrose
While kangaroo care and oral sucrose were effective in reducing solution in term neonates receiving heel lance: a randomized, controlled trial.
the pain experienced during heel lancing in preterm newborns, Pediatrics, 122(3), 716e721.
kangaroo care was more effective than oral sucrose. The adverse Cong, X., Cusson, R. M., Walsh, S., Hussain, N., Ludington-Hoe, S. M., & Zhang, D.
(2012). Effects of skin-to-skin contact on autonomic pain responses in preterm
effects of oral sucrose have been reported in the literature. For these infants. The Journal of Pain, 13(7), 636e645.
reasons, kangaroo care, a natural and easy method of pain man- Cong, X., Ludington-Hoe, S., & Walsh, S. (2011). Randomized crossover trial of
agement, is recommended for preterm infants in NICU during kangaroo care to reduce biobehavioral pain responses in preterm infants: A
pilot study. Biological Research for Nursing, 13(2), 204e216.
invasive procedures. Derebent, E., & Yig
it, R. (2006). Yenidog
anda ag
rı: deg

erlendirme ve yo €netim. C.Ü.
Hemşirelik Yüksekokulu Dergisi, 10(2), 41e48.
Derebent, E., & Yig
it, R. (2008). Non-pharmacological pain management in
Acknowledgments newborn. F.Ü. Sag
Bil Derg, 22(2), 113e118.
Dinçer, S., Yurtçu, M., & Günel, E. (2011). Pain in newborns and non-pharmacologic
treatment procedures. Selçuk Tıp Dergisi, 27(1), 46e51.
No conflict of interest has been declared by the authors. We
Elsefary, F. A., Alsaedi, S. A., Louwrens, J., Sadiq, B. B., & Mersale, A. Y. (2009). Oral
would like to thank Editage (www.editage.com) for English lan- sucrose and a pacifier for pain relief during simple procedures in preterm
guage editing. infants: A randomized controlled trial. Annals of Saudi Medicine, 29(3),
184e188.
Gao, H., Xu, G., Gao, H., Dong, R., Fu, H., Wang, D., & Zhang, H. (2015). Effect of repeated
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Please cite this article as: Sen, E., & Manav, G., Effect of Kangaroo Care and Oral Sucrose on Pain in Premature Infants: A Randomized Controlled
Trial, Pain Management Nursing, https://doi.org/10.1016/j.pmn.2020.05.003