Patricia \200\231s work in these two cases was guided by a practice process of assessment, intervention, and outcome evaluation; her clinical reasoning was informed by theory. By ass essing the inter- action between the infant \200\231s developmental stage and the NICU envi ronment, with an occupation focus, Patricia \200\231s recommen- dations enable the parents to engage with their baby (parenting role, nurturing occupation). Drawing on a specifi c th eory related to infant development, Patricia \200\231s intervention plan minimizes threats to the infant \200\231s future occupational performance. Into Ben \200\231s routine at home and school, Patricia integrated spe- cifi c pain-relievi ng modalities thus facilitating his occupational roles. An outcome measure at baseline allo wed for later outcome evaluation, showing progress toward achieving Ben \200\231s goals. Case example Patricia is the consulting occupational therapist for the local hos- pital neonatal intensi ve care unit (NICU) 2 days per week and for a community school 3 days per week. At the hosp ital, a new infant is admitted overnight who has a signifi cant brain bleed and will requir e ongoing blood tests. Th e nurse asked that Patricia help teach the parents ways in which they can modify the infant \200\231s environment to support the infant \200\231s developmen t and to help with pain management. Using the synactive theory of develop- ment (Als, 1982) , Patricia describes how the environment in the NICU is developmentally unexpected and show s the parents how References Als, H. (1982). Toward a synactive theory of development: promise for the assess ment and support of infant individuality . Infant Mental Health J , 3 , 229 \200\223243 . American Occupational Th erapy Association Commission on Education. (2008). 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Th e reproducibility and validity of the Canadian Occupational Performance Measure in paren ts of children with disabilities. Clin Rehabil , 20 , 980 \200\223988 . Polatajko, H. J., Davis, J. A., Hobson, S. J. G., Landry, J. E., Mandich, A., Street, S. L. , et al . (2004). Meeting the responsibility that comes with privilege: introducing a taxon omic code for understanding occupation. Can J Occ Th er , 71 , 261 \200\223268 . Wilson, P. H. (2005). Practitioner review: approaches to assessment and treatment of childr en with DCD: an evaluative review. J Child Psychol Psychiatry , 46 (8), 806 \200\223823 . Polatajko, H., Davis, J., Stewart D., Cantin, N., Amoroso, B., Purdie, L., et al . (2007). Specifying the domain of concern: occupation as core. In E. A. Townsend, and H. J. Polatajk o (eds) Enabling occupation II: advancing an occupational therapy vision for health, well-b eing, & justice through occupation , pp. 9 \200\22336 . Ottawa ON : CAOT Publications ACE . Zwicker, J. G. and Harris, S. R. (2009). A refl ection on motor learning theory in pediatric occupational therapy. Can J Occ Th er , 76 (1), 29 \200\22337 . Supplementary online materials Figure 57.3 Handout \200\224recognizing pain behavior in you r child. Reproduced from Kuchta, G. and Davidson, I. (eds) Occupational and Physical Th era py for Children with Rheumatic Diseases: a clinical handbook, Radcli \200 e Shah, P. S., Aliwalas, L. L., and Shah, V. (2009). Breastfeeding or breast milk for procedu ral pain in neonates. Cochrane Neonatal Group. Cochrane Database of Syst Rev , 3 , CD004950 . CHAPTER 57 occupational therapy 599 Th erapy for Children with Rheumatic Diseases: a clinical handbook, Radcli \200 e Publishi ng, Oxford, Copyright Gay Kuchta and Iris Davidson 2008, with permission from Radcli \200 e Publishing. Publishing, Oxford, Copyright Gay Kuchta and Iris Davidson 2008, with permission from Ra dcli \200 e Publishing. Figure 57.4 Handout \200\224what to do when your child is in pain. Reproduced from Kuchta, G. and Davidson, I. (eds) Occupational and Physical Th erapy for Children with Rheumatic Di seases: a clinical handbook, Radcli \200 e Publishing, Oxford, Copyright Gay Kuchta and Iris Davidson 2008, with permission from Radcli \200 e Publishing. Figure 57.6 Handout \200\224fatigue management. Reproduced from Kuchta, G. and Davidson, I. (eds) Occupational and Physical Th erapy for Children with Rheumatic Diseases: a clinical handbook, Radcli \200 e Publishing, Oxford, Copyright Gay Kuchta and Iris Davidson 2008 , with permission from Radcli \200 e Publishing. Figure 57.5 Handout \200\224managing your child \200\231s pain with heat or cold. Reproduce d from Kuchta, G. and Davidson, I. (eds) Occupational and Physical CHAPTER 58 Mother care for procedural pain in infants Celeste Johnston and Marsha Campbell- Yeo Summary A major role of maternal care is to protect their infant from harm, including pain. Th e aim of this chapter is to review the evidence on the eff ectiveness of maternal strat egies that are effi cacious in manag- ing procedural pain including breastfeeding, kangaroo mother care, and facsimiles of maternal presence such as voice recordings, odor, and other care providers. Th e mechanisms, as currently understood, underlying the effi cacy of mate rnal care, will be presented. Finally, pragmatic issues, such as feasibility, will be discu ssed. studies, compared breastfeeding to sweet taste with mixed results. Bilgen found 25% sucrose more eff ective in decreasing heart rate change, crying, and recovery time (Bilgen et al., 2001). Carbajal et al. (2003) reported equivalent reduction in composite pain scores betwe en breastfeeding and glucose plus pacifi er. Codipietro et al. (2008) reported signifi cant diff erences on pain scores favoring breastfeeding over sucrose. Finally, Gradin et al. (2 004) reported that in combination, there were synergistic eff ects between 30% glucose plus breastfeeding. Results from a systematic meta-analysis of breastfeeding support its use as a comforting measure for pro- cedural pain in full-term infants (Shah et al., 2007). Pain scores measured using the Premature Infant Pain Profi le (PIPP; Stevens et al., 1996, 2010) composite pain measure were signifi cantly dif- ferent between the breastfeeding group and the placebo group (weighted mean diff erence: \210\222 6 (range \210\222 7 to \210\222 4)), but these scores were not diff erent when compared with the glucose plus pacifi er gro up (weighted mean diff erence: 1.30 (range: 0.05 to 2.56)) (Shah et al., 2007). Introduction Mammalian mothers almost universally take care of their young. Th is includes providing nourishment and protection from harm. Protection from harm, in the event of tissu e damage, encompasses providing comfort to assist the infant to return to a pre-injured sta te. In modern human history, particularly in developed countries, ill or very preterm infan ts are separated from their mothers, who then lose the nurturing and protective roles that are inherent in mother- hood. Even well babies undergoing routine medical care are oft en s eparated from their mothers. Infants are oft en removed from their mother \200\231s arms an d placed in a bassinet to undergo a painful proce- dure. Th is separation is executed in th e belief that health care pro- fessionals can care for the infant without the mother, and, in fact, that the mother may interfere with their ability to give the most effi cient care to the infant (Campbell-Yeo et al., 2008b). As pae- diatric hospitals and units move toward s family centered care, this separation is being questioned (Franck et al., 2011). Recent r eports from the literature can be used to support the inclusion of parents, especially moth ers, in the care of hospitalized infants including the role of providing comfort during pai nful events. Breast milk delivered by syringe alone (i.e. without a pacifi er or being held) is, in all but one study (Upadhyay et al., 2004), inef- fective in reducing pain (Bilgen et al., 2001; Blass, 1997; Blass and Miller, 2001; Ors et al., 1999). Th is fi nding is hypothesized to be rela- tive to the sweetness of sugars; where lactose in breast milk is much less sweet t han sucrose (Joesten et al., 2007; McDaniel et al., 1989). Th ese results raise certain que stions about why breastfeeding is eff ective, since breast milk administered alone is not. Sucking could be one component since sucking alone has been reported to have a pain reducin g eff ect (Bo and Callaghan, 2000). Maternal closeness could be another factor. Holding by the mother was more eff ective in reducing crying than both holding and sucrose alone but f acial actions of pain were decreased only by holding (Gormally et al., 2001). However, in a nother study, holding by mother was not as eff ective as glucose on pacifi er or breastfeed ing (Carbajal et al., 2003). Background Breast milk, breastfeeding Breast milk and breastfeeding are oft en considered t ogether for obvious reasons: you cannot have breastfeeding without breast milk or its precu rsor, colostrum. In full-term neonates, Gray and col- leagues reported there was signifi ca nt reduction in pain scores with breastfeeding compared to standard care (Gray et al., 2002 ). Other Th e evidence to support breastfeeding as a comfort measure is strong (Campbell-Yeo et al., 2011). At its weakest, breastfeeding is marginally less eff ective than sweet taste, but t he results are mixed. Th e underlying mechanisms are likely synergistic since neither holdi ng, breast milk alone, nor sucking alone can explain its eff ec- tiveness. For a more in-de pth discussion on sucrose and sweet taste in relieving pain in infants, please see Harrison et al. (Chapter 49, this volume). CHAPTER 58 mother care for procedural pain in infants 601 Skin-to-skin contact, or kangaroo mother care Skin-to-skin contact (SSC) between infant and mother is com- monly referred to as kangaroo mother care (KMC), due to its simi- larity to marsupial maternal care. Among behavioral and physical interventions for procedural pain i n the neonatal intensive care unit (NICU), SSC is of interest both because of its eff ectiv eness, but also in its centrality to family centered care. Currently, the comfort- ing role of mothers is lost in the typical NICU setting (Montirosso et al., 2012). Yet, pain their child experiences and the loss of that comforting parental role are among the highest sourc es of stress for mothers as well as fathers (Franck et al., 2005; Miles et al., 1989, 1993) . By giving mothers an opportunity to take on the comforting role of parenthood, they feel they are eff ective and closer to their infant (Campbell-Yeo et al., 2008a). (1986) studied pregnant women at 30 weeks of gestation who had recited a target story aloud to their fetuses twice daily until birth. At birth, the target story had greater reinforci ng value (measured by sucking bursts) to the novel story and was independent of who recited the story. In another study, pregnant women at 33 weeks of gestation recited a target rhym e three times daily for a succes- sion of 4 weeks which the fetuses diff erentially respond ed to with a brief decrease in fetal heart rate (DeCasper et al., 1994). DeCasper and Fifer (1980) examined full-term newborns within 3 days of life, and found that they preferred th eir mother \200\231s voice more than a female stranger \200\231s voice. In addition, the ne wborn, up to 8 months in age, can discriminate and show preference for their mother \200 \231s voice compared to a female stranger \200\231s voice (Standley and Masen, 1990). Fifer et al. (1995) found that newborns suck a non-nutritive nipple signifi cantly more oft en w hen syllables are paired with the mater- nal voice to syllables paired with another woman \200\231s voice or silence. When presented with a choice of hearing their own mother \200 \231s voice in speech or a fi ltered version in such a way as to mimic womblike sounds, new borns suck more oft en to the signal predicting the \200\230 in utero \200\231 versions o f their own mother \200\231s voice. KMC was implemented in the modern era as an alternative to the incubator to maintain preter m infants \200\231 body temperature and increase survival rate in South America where incub ators were in short supply (Charpak et al., 1994). During this time, it was ser- endipitous ly noted that infants spent more time in quiet sleep state (Ludington-Hoe et al., 2006). Mo re recently, analysis using electroencephalogram (EEG) sleep studies demonstrated that pre- term infants exposed to KMC daily for 8 weeks had fewer rapid eye movements, more quiet sl eep, and less spectral beta when com- pared to full-term infants, delivered at term or deli vered preterm and corrected to term equivalent who did not receive KMC (Scher and Loparo, 2 009). Since quiet state is associated with decreased pain response (Grunau and Craig, 1987; Stevens et al., 1996) the idea developed to use KMC for procedural pain management. Based on these data of infant auditory memory of their mother \200\231s voice, as well as m emory of maternal heartbeat, auditory record- ings compared THE EFFECTS OF recordings of ma ternal sounds have been tested on pain response in infants. Th e fi rst study with full-ter m neonates compared recordings of maternal heartbeat to Japanese drum (the study was conduc ted in Japan and the Japanese drum is soft and rhythmic) on salivary and serum cortiso resp onse following heel stick (Kurihara et al., 1996). Maternal heartbeat was more eff ective i n decreasing behavioral indicators of stress, meas- ured using facial and vocal response du ring heel lance as well as cortisol levels measured 20 min post lance. More recently, mater nal voice recordings of babytalk, nursery rhymes, or songs, played to preterm neonates duri ng quiet time and then during a heel lance procedure was no more eff ective than usual care with no sound (Johnston et al., 2007). In this study, the decibel levels of the record- in gs were above the recommended levels, as was the ambient noise of the study NICU, which may have interfered with the infant \200\231s abil- ity to process the actual sounds. Th e fi rst study examining the eff ect of KMC and pain response was conducted by Gray in 2 000, in full-term neonates where decreased crying and a lower heart rate acceleration were observed (Gray et al., 2000). Th ree years later, Johnston, in the fi rst study examining K MC with preterm neonates undergoing heel lance, reported a decrease in composite pain score s, as well as the individual components of decreased facial action, lower heart rate accele ration, and increased oxygen saturations for neonates receiving KMC compared to incu- bator care (Johnston et al., 2003). A 2-point reduction as measured using the PIPP (Stevens et a l., 1996) was found at 30, 60, and 90 sec aft er heel lance (Johnston et al., 2003) and at 90 sec (p <0.001) in a similar study by Johnston examining the pain response of very preter m infants (Johnston et al., 2008). An even larger diff erence was found by Akcan et al. (20 09) at 1, 2, and 3 min aft er heel lance or venepuncture (mean PIPP score of 7, 4, and 4 in the SSC group and 15, p <0.001, 15.5, p = 0.001 and 15, p = 0.047 in the control group). I n a Cochrane review on SSC for procedural pain in infants, 15 studies that meet the inclusi on criteria all showed positive results (Johnston et al., 2010) when compared to usual care (see Table 58.1 ). Two studies (Chermont et al., 2009; Freire et al., 2008) showed that KM C/SSC was more effi cacious than sweet taste. Maternal olfactory e \200 ects on pain response Th ere is similar olfactory as well as aud itory learning of mother in utero. When newborn infants, separated from their mothers, were exposed to amniotic fl uid, their mothers \200\231 breast odor, or no odor, the ones who w ere exposed to amniotic fl uid calmed more quickly and cried less (Varendi et al., 1998). F urthermore, in another study of infant preference measured through head turning towards odo r, infants showed recognition of their own mother \200\231s amniotic fl uid, versus amnioti c fl uid from other women (Schaal et al., 1998). Full- term infants also preferred the smel l of human milk, not necessarily their own mother \200\231s milk, over formula milk (Marlie r and Schaal, 2005). Th us, the potential use of the familiar maternal odor was tested as a n intervention for procedural pain in newborns. Auditory facsimiles of maternal presence While infants are in utero , sensory learning is t aking place, so that following birth, they have some knowledge of their mother \200\231s id enti- fi cation, notably auditory and olfactory (see later sections). During the third trim ester ( \211 27 weeks GA) fetuses are able to hear and respond behaviourally to sound and auditory stimuli (DeCasper and Fifer, 1980; Ockleford et al., 1988). DeCasper and Spence Goubet and colleagues conducted three studies on familiar odors versus non-familiar odors o n pain response in full-term infants (Goubet et al., 2003, 2007; Rattaz et al., 2005). All stud- ies demonstrated the eff ectiveness of a familiar smell, be it from mother or from co nditioning the infant to the smell of vanillan. One study compared odors of mother \200\231 s own milk, another wom- an \200\231s milk, formula milk, or no odor control on grimacing, crying, SECTION 8 physical interventions 602 Table 58.1 Studies examining the e \200 ect of kangaroo care (KC) on pain response Study Sample Design and intervention Provider Procedure Outcome measures Results in KMC N , GA Cry \206\223 by 82%, grimacing \206\223 by 65%, smaller \206\221 in beats/minute during blood collection (8 \200\22310 vs 36 \200\22338) (Gray et al., 2000) 30, full term RCT, 10 \200\22315 min, KC vs swaddled in cot Mother Heel lance Duration of cry, grimacing, HR PIPP scores signi \201 cantly \206\223 at 30 sec (MD, 1.5 points; P = 0.04), 60 sec (MD, 2.2 points; P = 0.002), and 90 sec (MD, 0.6 point; P = 0.37) after heel-lancing procedure. Heart rate and oxygen saturation similar in both conditions. Facial actions contributed sig ni \201 cantly to total pain score (0.000 <P <0.005), with facial actions averaging 20% gr eater in control vs KC condition. (Johnston et al., 2003) 74, 32 \200\22336 weeks GA RCT, crossover 30 min KC vs swaddled in incubator Mother Heel lance PIPP: facial actions, heart rate, oxygen saturation, gestational age, behavioral state (Ludington-Hoe et al., 2005) 23, mean 31 weeks GA RCT, crossover 3 h of KC vs incubator Mother Heel lance HR, respiratory rate, oxygen saturation, \206\223 crying, length of crying, behavioral sta te Mean rise in heart rate (F(1,32) = 3.01, P = 0.047) from baseline to heel lance was less in the KC condition than in the warmer condition Crying length during KC heel lance signi \201 cantly less than during warmer heel lance (F(1,32) = 7.38, P = 0.003) and post-lance p eriod (P = 0.02). 100 full term RCT, 10 min KC vs cot Mother IM injection Duration of cry, NIPS score Mean duration of crying post injection was longer, 24.61 in the control group vs 14.55 sec in the KC group p = 0.001. NIPS scores signi \201 cantly \206\223 immediately following i njection in KC, p <0.001 (Kashaninia et al., 2008; Sajedi et al., 2007) a NFCS score signi \201 cantly \206\223 at heel lance ( \210\222 1.140; p = 0.23) and sque eze phase ( \210\222 1.872; p <0.001). Cry \206\223 by 37.4%. No di \200 erence in HR (Castral et al., 2008) 59, 30 \200\22337 weeks GA RCT, 15 min KMC vs swaddled in incubator Mother Heel lance Facial action, NFCS score, behavioral state, duration of cry, HR (Freire et al., 2008) 95, 28 \200\22336 weeks GA RCT. 15 min KC vs oral glucose vs prone position in incubator Mother Heel lance Behavioral state, HR variation, Oxygen saturation, PIPP scores for facial actions No di \200 erence in behavioral state, \206\223 variation in (p<0.0001) and HR in oxygen saturation (p <0.0012), \206\223 scores for facial actions (p <0.0001) PIPP scores \206\223 at 90 sec (8.871 versus 10.677; p <0.001). Time to recover \206\223 in KC (123 sec (95%CI 103 \200\223142)) vs 193 sec for incubator (95% CI 158 \200\223227) ( F (61,1) = 13.6, p <0.000) (Johnston et al., 2008) 61 28 \200\22331 weeks GA RCT cross-over 15 min KC versus swaddled in incubator Mother Heel lance PIPP, time to recover (heart rate return to baseline), facial actions, HR, oxygen saturatio n \206\223 combined crying time during heel stick (55 vs 96.2 sec; p = 0.001) and during rec overy (5.8 vs 25.5 sec; p <0.01). Inaudible cry was minimal in each phase, in both conditio ns 0 \200\2231.34 sec (Kostandy et al., 2008) 10 Preterm 30 \200\22332 weeks GA RCT, crossover, 30 min KC vs nested in incubator Mother Heel lance Audible and inaudible crying (Anderson Behavioral State Scoring system) RCT, 45 min KC \227 5 days-procedure on 5th day. PIPP scores were \206\223 in the KC group, at the 1st, 2nd and 3rd min of the painful proc edure, 7.0, 4 and 4 in infants in KC group vs 15.0, 15.5 and 15.0 (p <0.001, p = 0.001, p = 0.047, respectively) (Akcan et al., 2009) 50, Preterm 26 \200\22336 weeks GA Mother Heel stick/ venepuncture PIPP score at 60, 90, 120 seconds following procedure (Continued) CHAPTER 58 mother care for procedural pain in infants 603 Table 58.1 (Continued) Study Sample Design and intervention Provider Procedure Outcome measures Results in KMC N , GA Chermont (Chermont et al., 2009) 640 Full term RCT. 2 min KC vs standard care vs 25% dextrose vs KC/dextrose Mother IM injection PIPP score. NFCS and NIPS Mean PIPP scores for the 4 groups were standard care, 6.9 2.3; KC, 6.2 2.0; 25% dextrose treatment, 6.8 1.6; KC plus 25% dextrose treatment, 5.9 2.1 (Cong et al., 2009) 14 Preterm 30 \200\22332 weeks RCT, crossover 60 min KC vs incubator (IC) Mother Heel lance Infant behavioral state, HR, HRV HR signi \201 cantly lower in the KC condition (146 9 bpm) than in IC (152 13 bpm) durin g baseline period (p <0.05) and Heel Stick period (KC 159 bpm vs IC 165 14 bpm, p <0. 05). HRV \206\221 stable in KC at baseline (p <01) and at heel lance (p <0.001) \206\223 motor disorganization F(129) = 6.716, p = 0.002; extension movements (F(1, 29) = 8.554, p < 0.0001); and an \206\221 in attention signs negative attention signs (F(1.29) = 27.000, p = 0.018) and positive attention signs ([F(1,29) = 3.077, p <0.05) during KC (Ferber and Makhoul, 2008) 30 Preterm 28 \200\22334 weeks RCT Crossover, 10 min KC vs incubator Mother Heel lance NIDCAP (Johnston et al., 2009) 90 32 \200\22336 weeks GA RCT, crossover, 30 min KC with additional rocking, singing, and sucking vs KC without addit ional stimulation Mother Heel lance PIPP, time to recover No signi \201 cant di \200 erences in PIPP scores or time to recover signi \201 cant, di \200 erences across sites (Cong et al., 2011) 28 Preterm 30 \200\22332 weeks RCT, crossover 14 infants, 80 min KC (Study 1); 10 infants, 30 min KC (Study 2) vs incubato r Mother Heel lance PIPP salivary and serum cortisol at baseline, heel warming, heel stick and recovery Study 1: no di \200 erences Study 2: \206\223 PIPP during recovery (p <0.05 to p <0.001), \206\223 salivary cortisol at the end of recovery (p <0.05) and \206\223 serum cortisol during heel lance condition during heel lance \206\223 PIPP in MKC, mean di \200 erence 1.4 at 30 sec, 1.5 at 60 sec. No di \200 erenc e at 90 sec and 120s sec. \206\223 time to recover (204 sec MKC, 246 sec FKC). PIPP scores \206\223 in both groups vs historical controls (Johnston et al., 2011) 62 Preterm 28 \200\22336 weeks RCT, crossover 30 min MKC vs FKC Mother Father Heel lance PIPP, time to recover a Same study bpm = beats per minute; FKC =father kangaroo care; GA = gestational age; HR = heart rate; H RV = heart rate variability; IM = intramuscular injection; KC = kangaroo care; MD = mean di \200 erence; MKC = mother kangaroo care; NFCS = Neonatal Facial Coding System; NIDCAP = N ewborn Individualized Developmental Care and Assessment Program; NIPS = Neonatal Infant Pai n Scale; PIPP = Premature Infant Pain Pro \201 le; RCT = randomized controlled trial.