Elisa Guadalupe Cano Chi2, Jesús Porfirio Huchim Villanueva2, Saúl May Uitz1*, Genny Josefina Madera Poot1 and Julia Alejandra Candila Celis1
Received: December 06, 2024; Published: December 16, 2024
*Corresponding author: Saúl May Uitz, Profesor de Carrera, Universidad Autónoma de Yucatán, México. Email ID: saul.may@correo.uady.mx
DOI: 10.26717/BJSTR.2024.60.009381
Objective: To synthesize the existing scientific evidence on the effectiveness of facilitated containment as a
non-pharmacological method to reduce pain in preterm infants.
Methodology: A systematic review was carried out following the guidelines of the PRISMA declaration. The
search was carried out in PubMed and EBSCO databases, Virtual Health Library (VHL), and Taylor and Francis
Magazine, and was complemented with free searches in Google Scholar and reverse search strategy. The quality
of the selected articles was assessed using the Cochrane tool to assess risk of bias. Finally, the level of evidence
and degree of recommendation were assigned through the Scottish Intercollegiate Guidelines Network (SIGN)
scale.
Results: Of the 41 scientific articles identified, 12 were eliminated during sampling, 29 were eligible for critical
appraisal, and 11 were included in the final analysis. These included systematic reviews with meta-analyses,
clinical trials, and cohort studies. Methodological quality was high, with a moderate risk of bias. 90% of the
evidence presented a recommendation grade A, and 10% a grade B. The levels of evidence were 1++ (10%), 1+
(80%), and 2++ (10%).
Conclusion: Facilitated containment proves to be an effective method to reduce pain in preterm infants, with
additional benefits in physiological parameters, crying duration, and sleep patterns. This non-pharmacological
approach represents a promising and evidence-based intervention for neonatal pain management.
Keywords: Newborn Containment; Facilitated Tucking; Pain; Newborn; Premature
Abbreviations: VHL: Virtual Health Library; SING: Scottish Intercollegiate Guidelines Network; NICU: Neonatal Intensive Care Units; DeCS: Descriptors in Health Sciences; MeSH: Medical Subject Headings; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; CF: Facilitated Containment
Preterm infants face multiple challenges in their adjustment to life outside the womb, including frequent exposure to painful procedures as part of the intensive care necessary for their survival. In Neonatal Intensive Care Units (NICUs), pain is a constant due to the numerous invasive procedures that are routinely performed, such as blood draws, catheter insertion, and vital signs monitoring. According to Blazquez, et al. [1], premature infants can respond to these stimuli as early as 26 weeks of gestation, which shows their ability to perceive pain and hypersensitivity to painful stimuli at this early stage of development. Pain in the preterm infant has significant multi-system consequences. According to Álvarez, et al. [2], the experience of pain can induce a series of adverse physiological responses, such as the reduction of minute volume and lung vital capacity, which can trigger metabolic acidosis. It also increases cardiovascular demand by increasing blood pressure and heart rate, while at the endocrine level blood glucose and other metabolic markers are raised. The sympathetic nervous system reacts to pain by altering blood perfusion and generating changes in body temperature, effects that negatively impact the stability of the newborn. The incidence of painful procedures in these units is high, with an estimated 7.5 to 17.3 daily interventions per patient, with a higher prevalence in premature infants, who are continuously exposed to these interventions (Collados, et al. [3]).
Pain management in neonates has involved the use of pharmacological and non-pharmacological methods. However, in premature infants, the use of pharmacological analgesics presents additional risks due to the immaturity of their metabolic system, which increases the half-life of the drugs and complicates their elimination, exposing them to possible overdoses and adverse side effects (Vidal, et al. [4,5]). In contrast, nonpharmacological interventions have demonstrated benefits without these negative effects, providing tactile, vestibular, and kinesthetic stimuli that modulate the neonatate’s behavioral state, promote maturation, and reduce stress (Pérez, et al. [6]). A non-pharmacological technique of growing interest is facilitated tucking, which consists of holding and positioning the newborn to provide tactile stimuli for comfort. According to Cignacco, et al. [7], this technique offers multiple benefits without requiring advanced technologies, reducing costs and reducing exposure to pharmacological interventions. In addition, facilitated containment not only decreases pain and stress, but also supports the neurological development and adaptation of the newborn to life outside the womb.
There are several studies that have shown the efficacy of facilitated containment in reducing pain in newborns (Hartley, et.al. [8]) being a simple, safe and economical technique (Hasanat et.al. [9]), on the other hand, it reduces stress levels by improving stability in various systems (Hill, et.al. [10]), and in combination with other non-pharmacological techniques, the beneficial effects are enhanced (Osborne, et al. [11]). The present study aims to conduct a systematic review on the efficacy of facilitated containment to reduce pain in preterm infants, exploring its benefits and limitations. Through this research, we seek to provide evidence for its application in neonatal clinical settings, promoting safer and less invasive care for the most vulnerable patients in NICUs.
This study is a quantitative research that is framed within a type of systematic review, in which a compilation, analysis and synthesis of information obtained from various previously published scientific sources was carried out. The research question was carried out according to the IOP (Question, Intervention and Outcome) model. Components of the research question included Facilitated Tucking, preterm infants, pain reduction (Figure 1). Once the clinical research question was formulated, a detailed protocol was established to plan the process of searching for scientific evidence, which consisted of making a detailed list of words in everyday language. These components were converted to an indexed language for documentary search, using both Health Sciences Descriptors (DeCS) [12] and Medical Subject Headings (MeSH) [13] in Spanish, English, Portuguese and French (Table 1).
Note: Source: Own elaboration by Cano-Huchim based on *DECS **MeSH.
Search Protocol
To locate the scientific evidence, a search team was formed composed of 2 reviewers with clinical experience and previous training in the preparation of systematic reviews. A period was established for its development which comprised 3 months, these being September, October and November of the year 2024. In order to obtain high-quality articles in information, systematic tools and methods were implemented to ensure that the collection of these data was accurate, consistent and error-free.
Search Strategies
An exhaustive search was carried out for articles that will address the topic of interest which have been published from 2018 to date in the databases: Virtual Health Library (VHL) [14], PubMed [15], EBSCO [16] and Taylor and Francis journal [17]; as well as, free searches were carried out through Google Scholar [18] and vice versa. The guidelines established by the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement [19] were followed, and the selection or discarding of the articles found was carried out.In order to optimize the efficiency of the search, the AND operator was used, which allowed combining terms and establishing logical relationships between the key concepts that are part of the research question, based on the PIO model. Search strings were formulated: Facilitated Tucking AND Premature Birth AND Pain; Facilitated Tucking AND pain AND newborn AND neonatal (Table 2). The publications found were archived and organized using the Mendeley bibliographic manager, which was used for the generation of references, on the other hand, a search log executed in Microsoft Word was also used, in order to organize the articles found. For the eligibility and inclusion of scientific evidence, the following criteria were considered: [20-48].
Eligibility Criteria
Articles designed as systematic reviews with meta-analyses or simple systematic reviews. Experimental scientific articles from randomized clinical trials. Quasi-experimental scientific articles from non-randomized clinical trials. Pre-experimental scientific articles such as pre-test and post-test, Observational scientific articles of the cohort type. Scientific articles that address the research topic in languages: Spanish, English and Portuguese.
A total of 41 pieces of scientific evidence were identified, of which 8 were excluded for: duplicity, 4 for not retrieving the primary document, 17 for not meeting the objective, 1 for being in a language that is not within the inclusion criteria; 29 were eligible and as a result, it was decided to incorporate 11 articles in the final review, which met the established inclusion criteria (Figure 2).To determine the quality of the eligible evidence, a rigorous evaluation of the identified studies was carried out using critical reading sheets developed in the FLC 3.0 web application [49]. In these, a review of the methodology developed in the studies and its applicability in a real scenario was carried out, such as the study description, research question, method, results, conclusions, conflict of interest, and external validity.
Risk of Bias
The quality of the selected articles was independently established using the Cochrane tool for the assessment of risk of bias, the results obtained after the implementation of the instrument were summarised in a figure for analysis (Figure 3). Subsequently, based on the chosen articles, a hierarchy was made, assigning the level of evidence and degree of recommendation according to the design of the included studies according to the SIGN proposal [50], which includes: 1 systematic review with meta-analysis, 7 clinical trials, 1 pretest and post-test studies, 1 quasi-experimental study and 1 cohort study (Table 3).
Note: Source: Authors. Cano-Huchim 2024.
Consistently reviewed studies highlight the efficacy of facilitated containment in reducing pain levels in preterm infants. Avcin and Kucukoglu [51] found that this technique caused significantly less pain and crying during heel puncture compared to other methods such as breastfeeding and kangaroo care (p < 0.05). This finding reinforces the superiority of facilitated containment as a primary intervention for pain management. Lopez, et al. [52] confirmed these results, reporting that Preterm Infant Pain Profile scores were significantly lower in the treatment group compared to the control group. This finding supports the validity of this intervention to minimize pain perception in neonates. Similarly, Oktaviani, et al. [53] observed that infants in the intervention group cried for a shorter time than those in the control group during procedures such as blood collection, highlighting the role of this technique in promoting pain management as an integral part of developmental care. Reyhani, et al. [54] also support these results, showing that the duration of crying in the neonates in the intervention group was significantly shorter compared to the control group (p < 0.05). This finding underscores the importance of implementing strategies such as facilitated containment to promote child growth and development by minimizing the stress derived from painful procedures.
In addition to pain, facilitated containment has also shown a positive impact on stabilizing physiological parameters, essential for the recovery and well-being of neonates. Altay and Kucukoglu [55] documented significant improvements in heart rate, oxygen saturation, body temperature, and respiratory rate in the intervention group (p < 0.001). These observations are consistent with the findings of Obeidat, et al. [56], who reported significant improvements in heart rate, oxygen saturation, and sleep-wake status, in addition to lower pain scores. However, Peyrovi, et al. [57] did not observe significant differences in some parameters, such as the mean time to reach a minimum pain score or changes in oxygen saturation. However, minor changes in heart rate were highlighted in the intervention group, suggesting that the effectiveness of facilitated containment may vary depending on the individual characteristics of the infants and the study conditions. A prominent aspect in the literature is the potential for facilitated containment to actively involve parents in the care of their infants.
Axelin, et al. [58] stress that this technique can be safely and effectively applied by parents during procedures such as aspiration, promoting an active role in pain management. Not only does this parental involvement improve bonding, but it may also decrease anxiety in caregivers and strengthen confidence in their ability to support the baby’s well-being. Although other non-pharmacological methods, such as kangaroo and breastfeeding, have also shown efficacy in reducing neonatal pain, Avcin and Kucukoglu [51] highlighted that facilitated containment was superior in terms of crying reduction and pain scores. This positions it as a preferred option in contexts where the implementation of more complex techniques may not be feasible. While the evidence reviewed strongly supports the efficacy of facilitated containment, some studies, such as that of Peyrovi, et al. [57], identify limitations that deserve attention. These include small sample sizes, variability in methods, and differences in baseline characteristics of infants. Future research should focus on overcoming these limitations through more robust methodological designs that improve masking and/or concealment, also exploring the impact of this technique on long-term neurological development.
Facilitated containment has been consolidated as an effective and accessible intervention for pain management, 90% of the evidence presented a recommendation grade A, and 10%, grade B, in preterm infants. The studies reviewed support its effectiveness in reducing pain perception, making it a key strategy in the management of neonatal pain, the levels of evidence were 1++ (10%), 1+ (80%) and 2++ (10%), in intensive care units. However, further research is needed to address current limitations, such as discrepancies in observed effects and variability in neonatal response. As protocols are refined and knowledge about the underlying mechanisms of CF expands, it is expected that this technique will become standard practice in pain management in preterm infants.
To the Faculty of Nursing of the Autonomous University of Yucatan and to our advisors for the accompaniment in carrying out this work.
The authors declare that they have no conflict of interest whatsoever in relation to this work.