Twenty-four preterm infants 30-32 weeks gestational age and between 2-9 days postnatal age will be recruited for a cross-over design study to test the effect of Kangaroo Care (KC), skin -to - skin holding of the diaper-clad infant by the mother, on blunting physiologic, hormonal, and behavioral responses to heel stick. Heel stick is the most common repetitive painful procedure hospitalized premature infants experience. Pain experiences, both acute and chronic, are associated with impaired neurologic and immunologic functioning. Kangaroo Care may be an additional pain management intervention should it have an effect on blunting heart rate (HR), plasma and salivary cortisol, Premature Infant Pain Profile (PIPP) score and crying duration as well as increasing heart rate variability (HRV) in response to heelstick pain. Data will be collected over two days with all heelsticks occurring at 11:00 a.m. as part of routine blood draws for the daily labs. Infants are randomly assigned to group A (KC on Day 1, routine incubator care Day 2) or group B (routine incubator care Day 1, KC on Day 2). Infants will lie in an incubator for routine incubator care from 10:00-11:30, having the heel stick in the incubator; on the KC day infants will be in KC from 10:00 - 11:30 a.m. and have the heel stick done in KC. For both groups, at 10:45 a.m., HR and HRV recording, voice-activated recording for cry duration, videotaping for PIPP, and behavioral state measures (an intervening variable) will begin. At 11:00 a.m. a salivary cortisol sample and then a plasma cortisol sample are obtained. A second salivary cortisol sample will be obtained 21-minutes post-heelstick. At the end of the second salivary cortisol sampling, HR, HRV, cry duration, and behavioral state measurements cease. PIPP is scored for each phase of the heel stick sequence. Salivary cortisol correlates well with serum levels and will provide data on peak hormonal responses that occur 20-21 minutes after heelstick. Serum and salivary hormone levels will be determined by commercially available laboratory assay kits. Mean HR will be calculated from the pulse oximeter data; HRV will be computed for a total value, low and high frequency values, and ratio of low: high frequency. Duration of crying will be measured by the Tandy voice activated recorder and PIPP will be scored by a trained observer who is blind to treatment conditions. HRV will be analyzed with Fast Fourier Transformation and with all other outcomes, will be analyzed using an unpaired T-test if measurements are normally distributed. If the normality assumption is violated, an appropriate transformation will be used before applying the T-test.

National Institute of Health (NIH)
National Institute of Nursing Research (NINR)
Small Research Grants (R03)
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Special Emphasis Panel (ZRG1-NURS (02))
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Bryan, Yvonne E
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Case Western Reserve University
Schools of Nursing
United States
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Cong, Xiaomei; Ludington-Hoe, Susan M; Walsh, Stephen (2011) Randomized crossover trial of kangaroo care to reduce biobehavioral pain responses in preterm infants: a pilot study. Biol Res Nurs 13:204-16
Scher, Mark S; Ludington-Hoe, Susan; Kaffashi, Farhad et al. (2009) Neurophysiologic assessment of brain maturation after an 8-week trial of skin-to-skin contact on preterm infants. Clin Neurophysiol 120:1812-8
Jarrell, Julia R; Ludington-Hoe, Susan M; Abouelfettoh, Amel (2009) Kangaroo care with twins: a case study in which one infant did not respond as expected. Neonatal Netw 28:157-63
Cong, Xiaomei; Ludington-Hoe, Susan M; McCain, Gail et al. (2009) Kangaroo Care modifies preterm infant heart rate variability in response to heel stick pain: pilot study. Early Hum Dev 85:561-7
Kostandy, Raouth R; Ludington-Hoe, Susan M; Cong, Xiaomei et al. (2008) Kangaroo Care (skin contact) reduces crying response to pain in preterm neonates: pilot results. Pain Manag Nurs 9:55-65
Walters, Mary W; Boggs, Kim M; Ludington-Hoe, Susan et al. (2007) Kangaroo care at birth for full term infants: a pilot study. MCN Am J Matern Child Nurs 32:375-81
Ludington-Hoe, Susan M; Lewis, Tina; Morgan, Kathy et al. (2006) Breast and infant temperatures with twins during shared Kangaroo Care. J Obstet Gynecol Neonatal Nurs 35:223-31
Ludington-Hoe, Susan M; Johnson, Mark W; Morgan, Kathy et al. (2006) Neurophysiologic assessment of neonatal sleep organization: preliminary results of a randomized, controlled trial of skin contact with preterm infants. Pediatrics 117:e909-23
McCain, Gail C; Ludington-Hoe, Susan M; Swinth, Joan Y et al. (2005) Heart rate variability responses of a preterm infant to kangaroo care. J Obstet Gynecol Neonatal Nurs 34:689-94
Ludington-Hoe, Susan M; Hosseini, Robert; Torowicz, Deborah L (2005) Skin-to-skin contact (Kangaroo Care) analgesia for preterm infant heel stick. AACN Clin Issues 16:373-87