Pacifier and swaddling effective in impeding premature infant's pain score and heart rate

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These invasive procedures can cause stress to the infants and lead to frequent stress response<a class="elsevierStyleCrossRef" href="#bib0015">3</a>,<a class="elsevierStyleCrossRef" href="#bib0020">4</a>. The Synactive Theory of Development proposed by Als in 1982 was relevant to this phenomenon. The theory consists of five subsystems: autonomic stability (physiological parameters), motor control (body movement); state control (sleep cycle), interaction and social responsiveness, and self-regulation<a class="elsevierStyleCrossRef" href="#bib0025">5</a>. During the invasive procedure, there will be over stimulation that influences all subsystems in infants. Those influences include instability in heart rate, oxygen saturation, and respiration rate. The changes in the motor subsystem are manifestated by hand and leg agitation activities; while the changes in state subsystem can be manifested by infant sleep disturbances<a class="elsevierStyleCrossRefs" href="#bib0030">6–8</a>. Those changes can influence the process of brain nerve myelinization that can cause development disturbances in the short and long term periods<a class="elsevierStyleCrossRef" href="#bib0045">9</a>.<a name="p2"></a>The non pharmacologic pain management has been developed years ago. Previous studies had been analyzed the effectiveness of swaddling in pain controlling<a class="elsevierStyleCrossRef" href="#bib0050">10</a>, physiological function<a class="elsevierStyleCrossRef" href="#bib0055">11</a>, safety<a class="elsevierStyleCrossRef" href="#bib0060">12</a>, and sleep<a class="elsevierStyleCrossRef" href="#bib0065">13</a>. Meanwhile, the use of pacifier had been proved to prevent heart variability<a class="elsevierStyleCrossRef" href="#bib0070">14</a>, and as a means of pain control<a class="elsevierStyleCrossRef" href="#bib0075">15</a>,<a class="elsevierStyleCrossRef" href="#bib0080">16</a>. A numbers of previous studies have used combination between pacifier and sucrose<a class="elsevierStyleCrossRefs" href="#bib0085">17–21</a>, and facilitated tucking<a class="elsevierStyleCrossRef" href="#bib0030">6</a>,<a class="elsevierStyleCrossRef" href="#bib0040">8</a> in dealing with premature infants’ pain who undergoing several invasive procedures such as heel-stick procedure, intramuscular injection of Hepatitis Vaccine, or intra venous insertion. However, there are limited studies in using combination between pacifier and swaddling in different pain procedures in preterm infants.MethodThis study was a prospective randomized controlled trial with parallel design approach. Each sample received one type of invasive procedure such as hill-prick or venous access which was randomly allocated to the infants receiving pacifier and swaddling (Group A) or routine care (Group B). The blinding process was carried out by two experts to evaluate pain scores<a class="elsevierStyleCrossRef" href="#bib0110">22</a>.The study sample was selected based on the convenience sampling from the special care unit and Neonatal Intensive Care Unit at Dr. Cipto Mangunkusumo Hospital, Jakarta. There were 30 preterm infants who met the criterias: (1) gestational age 26-36 weeks; (2) 2-30 days of post birth age, and (3) birth weight < 2500 g. The exclusion criteriaswere: (1) infants on sedative treatment, muscle relaxant, antiepileptic or analgesic drugs; (2) have congenital anomalies; (3) have neurological problems and history of neonatal seizure, and (4) experience severe physiological alteration.Pain scores and physiological functions were measured 15 minutes before invasive procedure (baseline/T1). The intervention (pacifier and swaddling) was applied three minutes before the invasive procedure started (T2). The next measurements were carried out at the beginning of invasive procedure (T3), three minutes (T4) and 15 minutes after the procedure ending (T5). These measurements conducted in two days consequently in both groups.Infants’ pain was measured using the Premature Infant Pain Profile (PIPP) which was developed by Steven, Jhonston, Pethrysen, and Taddion<a class="elsevierStyleCrossRef" href="#bib0115">23</a>. The PIPP is reported to have a moderate internal consistency (0.59-0.76 item total correlation), high interrater reliability (0.95-0.97) and intrarater reliability (0.89-0.91)<a class="elsevierStyleCrossRef" href="#bib0035">7</a>,<a class="elsevierStyleCrossRef" href="#bib0120">24</a>.The Ethical clearance was obtained from the Ethical Research Committee, Faculty of Nursing Universitas Indonesia (0244/UN2.F12.D/HKP.02.04/2015) and the Ethical Research Committee, Faculty of Medicine Universitas Indonesia (0244/UN2.F12.D/HKP.02.04/2015). Written informed consent was obtained from mothers.Pain score and physiological responses were measured five times (T1, T2, T3, T4, and T5). Data were rated by two experts. A Bland Altmant test was carried out to test the interrater reliability of two experts and the result were 0.632 and 1.99 in the range of –5 to +5. It means that there was a similar perception between experts.Chi-square test was used to test the homogeneity of data in both control and intervention groups. The hypothesis was tested using dependent and independent t-test with the level of significance was 0.05.ResultsThe result of the homogeneity test showed that there were no significant differences in infants’ characteristics between control and intervention groups. The characteristics were gestational age, chronological age, the length of stay, birth weight, body weight, length of the invasive procedure, gender, type of invasive procedure, and Apgar score.The output of this study was the comparison of pain score, saturation, heart rate differences before and after invasive procedures between intervention and control groups (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). There were no significant differences in all variables. However, there were significant differences in several spots of measurements between two groups (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia>The peak score of pain was during the invasive procedure. The score increased 6.67 point in the control group compared to 2.34 point in the intervention group. The increase of pain score was significant in the control group (p=0.003) (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The heart rate increased in both groups during the procedure, and it decreased significantly in the intervention group after the procedure (p=0.013).The oxygen saturation was decreased in both groups and relieved three minutes after the procedure. There was no significant difference in oxygen saturations before, during, and after procedures between two groups.DiscussionThe low score of pain and stability of physiological function are the main objectives of non-pharmacologic pain management. The main objectives of this study were to measure the differences in pain score, saturation, and heart rate before, during, and after procedures between infants who received pacifier and swaddling, and the control group who received routine care. Based on those indicators, there were no significant effect of pacifier and swaddling in reducing pain score, stabilizing heart rate, and oxygen saturation. This result was relevant with previous studies that providing pacifier were not significantly reducing the pain score in preterm infants<a class="elsevierStyleCrossRef" href="#bib0125">25</a> and preventing alteration in heart rate<a class="elsevierStyleCrossRef" href="#bib0070">14</a>. Other studies also found that using pacifier and swaddling was not effective in preventing oxygen saturation variability<a class="elsevierStyleCrossRef" href="#bib0130">26</a>. Longer stimulation is needed to give effect on the oxygen saturation changes<a class="elsevierStyleCrossRef" href="#bib0130">26</a>.On the other hand, several studies had different finding with this study. The previous study identified that pacifier with sucrose can decrease infant's pain<a class="elsevierStyleCrossRef" href="#bib0085">17</a>. A meta-analysis of 10 articles identified that providing pacifier can decrease pain responses<a class="elsevierStyleCrossRef" href="#bib0080">16</a> and decrease pain score in term and preterm infants<a class="elsevierStyleCrossRef" href="#bib0040">8</a>,<a class="elsevierStyleCrossRef" href="#bib0100">20</a>. Review articles also found that pacifier can decrease infants’ pain score<a class="elsevierStyleCrossRef" href="#bib0135">27</a>,<a class="elsevierStyleCrossRef" href="#bib0140">28</a>.This study was different with previous studies in term of infant gestational age. In the previous studies, gestational age of the infants involved was more than 37 weeks<a class="elsevierStyleCrossRef" href="#bib0085">17</a>,<a class="elsevierStyleCrossRef" href="#bib0100">20</a>; meanwhile, in this study the gestational age of the infant was less than 37 weeks. Preterm infants are more sensitive<a name="p3"></a><a name="p4"></a> to stimuli which characterized by physiological changes, ineffective regulation, and negative cues<a class="elsevierStyleCrossRefs" href="#bib0150">30–32</a>.Prematurity can lead the increase of hearth rate, respiration rate, and oxygen saturation compared to term infants. Besides that, our study did not measure baseline data of infant state which was done in the previous study that may influence the difference of physiological function indicators.The pain observation in this study was two days, meanwhile the observation in the previous studies was carried out in three and five days<a class="elsevierStyleCrossRef" href="#bib0040">8</a>,<a class="elsevierStyleCrossRef" href="#bib0100">20</a>. Furthermore, the previous studies measure the mean score of the whole observation period<a class="elsevierStyleCrossRef" href="#bib0085">17</a>,<a class="elsevierStyleCrossRef" href="#bib0100">20</a>, while this study using different score between before and after the procedure. This study is also different with other previous study in regard to the intervention used. This study used a combination between pacifier and swaddling, yet other studies used a combination of pacifier-facilitated tucking<a class="elsevierStyleCrossRef" href="#bib0040">8</a>, also pacifier and sucrose<a class="elsevierStyleCrossRef" href="#bib0085">17</a>,<a class="elsevierStyleCrossRef" href="#bib0100">20</a>.However, our study found that pacifier and swaddling impeding the increase of pain score during acute period (during procedure-three minutes after the procedure). The frequency of heart rate also decreased faster in the pacifier and swaddling group compared to infants in the routine care group. The decrease of heart rate was faster significantly in the pacifier and swaddling group (p=0.013) (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Physiologically, heart rate, respiration rate, blood pressure, intracranial pressure of infants who receive pain procedure will increase. This response due to the release of adrenal stress hormones associated with pain<a class="elsevierStyleCrossRef" href="#bib0035">7</a>. The pain was impeded by the antinociceptive effect of application pacifier and swaddling that can reduce pain sensation<a class="elsevierStyleCrossRef" href="#bib0085">17</a>.Based on Gate Control Theory, applying pacifier and swaddling can impede the transfer of pain impulse along the spinothalamic tract that can reduce the pain sensation<a class="elsevierStyleCrossRef" href="#bib0140">28</a>,<a class="elsevierStyleCrossRef" href="#bib0165">33</a>. The combination of pacifier and swaddling can increase the stimuli that sift transferring pain stimuli which can generate stronger analgesic effect<a class="elsevierStyleCrossRef" href="#bib0145">29</a>,<a class="elsevierStyleCrossRef" href="#bib0170">34</a>. Pacifier and swaddling are simple tools that are easy to find in the developing country.Conflicts of interestThe authors declare that they have no conflicts interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:3 [ "identificador" => "xres1092659" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1035531" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Method" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1035531" "palabras" => array:5 [ 0 => "Premature" 1 => "Pacifier" 2 => "Swaddling" 3 => "Invasive procedure" 4 => "Pain" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo assess the effectiveness of pacifier and swaddling on premature infant's pain score, hearthrate, and oxygen saturation during an invasive procedure. MethodThis randomized control trial involv 30 premature infants who were randomly assigned into control (n=15) and intervention (n=15) groups using parallel design. Infants in the intervention group received pacifier and swaddling when they were undergoing invasive procedures. The outcome indicators of the two-day intervention were pain score, hearth rate, and oxygen saturation. The Premature Infant Pain Profile (PIPP) was used in this study to measure infants’ pain. ResultsThe paired t-test results showed that the pain score and heart rate were significantly increased following the procedure in the control group (p=0.003; p=0.013 < 0.05); meanwhile, there was no significant increase in the intervention group (p=0.256; p=0.783 > 0.005). There was no significant different in oxygen saturation in the control group (p=0.270) and in the intervention (p=0.370) group before and after the procedure. ConclusionsProviding pacifier and swaddling can impede the increase of premature infants’ pain score and hearth rate during an invasive procedures, therefore it can be implemented as an alternative to pain management in premature infants." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 608 "Ancho" => 997 "Tamanyo" => 60798 ] ] "descripcion" => array:1 [ "en" => "Pain score of the preterm infant (n=30)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 604 "Ancho" => 989 "Tamanyo" => 67810 ] ] "descripcion" => array:1 [ "en" => "Heart rate of the preterm infant (n=30)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 634 "Ancho" => 992 "Tamanyo" => 62346 ] ] "descripcion" => array:1 [ "en" => "The mean of oxygen saturation of the preterm infant (n=30)." ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "Difference: the result from mean after invasive procedure minus mean before invasive procedure. Between groups: the comparison of mean differences between intervention and control groups." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Measurement indicator \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">N (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mean±SD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Within group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Between group \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">t (p)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">t (p)<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " colspan="6" align="left" valign="top">Pain score</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Before \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.93±2.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.81 (0.783) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">After \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.13±2.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Difference \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.33±2.90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Control \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Before \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.40±1.84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.56 (0.003)<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">After \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.67±2.74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Difference \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−2.33±2.58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.00 (0.056) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " colspan="6" align="left" valign="top">Hearth rate</td> </tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Before \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">139.40±13.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.18 (0.256) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">After \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">144.33±20.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Difference \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−4.93±16.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Control \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Before \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">149.63±11.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.84 (0.013)c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">After \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">158.57±18.90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Difference \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−8.93±12.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.77 (0.450) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " colspan="6" align="left" valign="top">Oxygen saturation</td> </tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Before \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96.80±3.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.16 (0.267) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">After \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96.13±2.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Difference \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8±2.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Control \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Before \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96.33±4.62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.92 (0.370) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">After \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97.13±4.66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Difference \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8±3.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.48 (0.150) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1868629.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Calculated by dependent t-test." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Calculated by independent t-test." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "Significant at a < 0.05." ] ] ] "descripcion" => array:1 [ "en" => "Comparison of treatment effects on pain score, hearth rate and oxygen saturation (n=30)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:34 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Newnham CA, Inder TE, Milgrom J. 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Defi Efendi

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defiefendi86@gmail.com

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, Yeni Rustina, Dewi Gayatri

Faculty of Nursing, Universitas Indonesia, Depok, Jawa Barat, Indonesia

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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Heart rate of the preterm infant &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Premature infants receive invasive procedures for 93 times during hospitalization<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; These invasive procedures can cause stress to the infants and lead to frequent stress response<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; The Synactive Theory of Development proposed by Als in 1982 was relevant to this phenomenon&#46; The theory consists of five subsystems&#58; autonomic stability &#40;physiological parameters&#41;&#44; motor control &#40;body movement&#41;&#59; state control &#40;sleep cycle&#41;&#44; interaction and social responsiveness&#44; and self-regulation<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; During the invasive procedure&#44; there will be over stimulation that influences all subsystems in infants&#46; Those influences include instability in heart rate&#44; oxygen saturation&#44; and respiration rate&#46; The changes in the motor subsystem are manifestated by hand and leg agitation activities&#59; while the changes in state subsystem can be manifested by infant sleep disturbances<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a>&#46; Those changes can influence the process of brain nerve myelinization that can cause development disturbances in the short and long term periods<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46;<a name="p2"></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The non pharmacologic pain management has been developed years ago&#46; Previous studies had been analyzed the effectiveness of swaddling in pain controlling<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#44; physiological function<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#44; safety<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#44; and sleep<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#46; Meanwhile&#44; the use of pacifier had been proved to prevent heart variability<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#44; and as a means of pain control<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46; A numbers of previous studies have used combination between pacifier and sucrose<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#8211;21</span></a>&#44; and facilitated tucking<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> in dealing with premature infants&#8217; pain who undergoing several invasive procedures such as heel-stick procedure&#44; intramuscular injection of Hepatitis Vaccine&#44; or intra venous insertion&#46; However&#44; there are limited studies in using combination between pacifier and swaddling in different pain procedures in preterm infants&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Method</span><p id="par0015" class="elsevierStylePara elsevierViewall">This study was a prospective randomized controlled trial with parallel design approach&#46; Each sample received one type of invasive procedure such as hill-prick or venous access which was randomly allocated to the infants receiving pacifier and swaddling &#40;Group A&#41; or routine care &#40;Group B&#41;&#46; The blinding process was carried out by two experts to evaluate pain scores<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The study sample was selected based on the convenience sampling from the special care unit and Neonatal Intensive Care Unit at Dr&#46; Cipto Mangunkusumo Hospital&#44; Jakarta&#46; There were 30 preterm infants who met the criterias&#58; &#40;1&#41; gestational age 26-36 weeks&#59; &#40;2&#41; 2-30 days of post birth age&#44; and &#40;3&#41; birth weight &#60; 2500 g&#46; The exclusion criteriaswere&#58; &#40;1&#41; infants on sedative treatment&#44; muscle relaxant&#44; antiepileptic or analgesic drugs&#59; &#40;2&#41; have congenital anomalies&#59; &#40;3&#41; have neurological problems and history of neonatal seizure&#44; and &#40;4&#41; experience severe physiological alteration&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Pain scores and physiological functions were measured 15 minutes before invasive procedure &#40;baseline&#47;T1&#41;&#46; The intervention &#40;pacifier and swaddling&#41; was applied three minutes before the invasive procedure started &#40;T2&#41;&#46; The next measurements were carried out at the beginning of invasive procedure &#40;T3&#41;&#44; three minutes &#40;T4&#41; and 15 minutes after the procedure ending &#40;T5&#41;&#46; These measurements conducted in two days consequently in both groups&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Infants&#8217; pain was measured using the Premature Infant Pain Profile &#40;PIPP&#41; which was developed by Steven&#44; Jhonston&#44; Pethrysen&#44; and Taddion<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#46; The PIPP is reported to have a moderate internal consistency &#40;0&#46;59-0&#46;76 item total correlation&#41;&#44; high interrater reliability &#40;0&#46;95-0&#46;97&#41; and intrarater reliability &#40;0&#46;89-0&#46;91&#41;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The Ethical clearance was obtained from the Ethical Research Committee&#44; Faculty of Nursing Universitas Indonesia &#40;0244&#47;UN2&#46;F12&#46;D&#47;HKP&#46;02&#46;04&#47;2015&#41; and the Ethical Research Committee&#44; Faculty of Medicine Universitas Indonesia &#40;0244&#47;UN2&#46;F12&#46;D&#47;HKP&#46;02&#46;04&#47;2015&#41;&#46; Written informed consent was obtained from mothers&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Pain score and physiological responses were measured five times &#40;T1&#44; T2&#44; T3&#44; T4&#44; and T5&#41;&#46; Data were rated by two experts&#46; A Bland Altmant test was carried out to test the interrater reliability of two experts and the result were 0&#46;632 and 1&#46;99 in the range of &#8211;5 to &#43;5&#46; It means that there was a similar perception between experts&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Chi-square test was used to test the homogeneity of data in both control and intervention groups&#46; The hypothesis was tested using dependent and independent t-test with the level of significance was 0&#46;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">The result of the homogeneity test showed that there were no significant differences in infants&#8217; characteristics between control and intervention groups&#46; The characteristics were gestational age&#44; chronological age&#44; the length of stay&#44; birth weight&#44; body weight&#44; length of the invasive procedure&#44; gender&#44; type of invasive procedure&#44; and Apgar score&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The output of this study was the comparison of pain score&#44; saturation&#44; heart rate differences before and after invasive procedures between intervention and control groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; There were no significant differences in all variables&#46; However&#44; there were significant differences in several spots of measurements between two groups &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The peak score of pain was during the invasive procedure&#46; The score increased 6&#46;67 point in the control group compared to 2&#46;34 point in the intervention group&#46; The increase of pain score was significant in the control group &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The heart rate increased in both groups during the procedure&#44; and it decreased significantly in the intervention group after the procedure &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;013&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The oxygen saturation was decreased in both groups and relieved three minutes after the procedure&#46; There was no significant difference in oxygen saturations before&#44; during&#44; and after procedures between two groups&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">The low score of pain and stability of physiological function are the main objectives of non-pharmacologic pain management&#46; The main objectives of this study were to measure the differences in pain score&#44; saturation&#44; and heart rate before&#44; during&#44; and after procedures between infants who received pacifier and swaddling&#44; and the control group who received routine care&#46; Based on those indicators&#44; there were no significant effect of pacifier and swaddling in reducing pain score&#44; stabilizing heart rate&#44; and oxygen saturation&#46; This result was relevant with previous studies that providing pacifier were not significantly reducing the pain score in preterm infants<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> and preventing alteration in heart rate<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46; Other studies also found that using pacifier and swaddling was not effective in preventing oxygen saturation variability<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#46; Longer stimulation is needed to give effect on the oxygen saturation changes<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">On the other hand&#44; several studies had different finding with this study&#46; The previous study identified that pacifier with sucrose can decrease infant&#39;s pain<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46; A meta-analysis of 10 articles identified that providing pacifier can decrease pain responses<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and decrease pain score in term and preterm infants<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; Review articles also found that pacifier can decrease infants&#8217; pain score<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">This study was different with previous studies in term of infant gestational age&#46; In the previous studies&#44; gestational age of the infants involved was more than 37 weeks<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#59; meanwhile&#44; in this study the gestational age of the infant was less than 37 weeks&#46; Preterm infants are more sensitive<a name="p3"></a><a name="p4"></a> to stimuli which characterized by physiological changes&#44; ineffective regulation&#44; and negative cues<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#8211;32</span></a>&#46;Prematurity can lead the increase of hearth rate&#44; respiration rate&#44; and oxygen saturation compared to term infants&#46; Besides that&#44; our study did not measure baseline data of infant state which was done in the previous study that may influence the difference of physiological function indicators&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The pain observation in this study was two days&#44; meanwhile the observation in the previous studies was carried out in three and five days<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; Furthermore&#44; the previous studies measure the mean score of the whole observation period<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#44; while this study using different score between before and after the procedure&#46; This study is also different with other previous study in regard to the intervention used&#46; This study used a combination between pacifier and swaddling&#44; yet other studies used a combination of pacifier-facilitated tucking<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#44; also pacifier and sucrose<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">However&#44; our study found that pacifier and swaddling impeding the increase of pain score during acute period &#40;during procedure-three minutes after the procedure&#41;&#46; The frequency of heart rate also decreased faster in the pacifier and swaddling group compared to infants in the routine care group&#46; The decrease of heart rate was faster significantly in the pacifier and swaddling group &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;013&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Physiologically&#44; heart rate&#44; respiration rate&#44; blood pressure&#44; intracranial pressure of infants who receive pain procedure will increase&#46; This response due to the release of adrenal stress hormones associated with pain<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; The pain was impeded by the antinociceptive effect of application pacifier and swaddling that can reduce pain sensation<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Based on Gate Control Theory&#44; applying pacifier and swaddling can impede the transfer of pain impulse along the spinothalamic tract that can reduce the pain sensation<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&#46; The combination of pacifier and swaddling can increase the stimuli that sift transferring pain stimuli which can generate stronger analgesic effect<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>&#46; Pacifier and swaddling are simple tools that are easy to find in the developing country&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts interest&#46;</p></span></span>"
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          "clase" => "keyword"
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          "palabras" => array:5 [
            0 => "Premature"
            1 => "Pacifier"
            2 => "Swaddling"
            3 => "Invasive procedure"
            4 => "Pain"
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    "resumen" => array:1 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To assess the effectiveness of pacifier and swaddling on premature infant&#39;s pain score&#44; hearthrate&#44; and oxygen saturation during an invasive procedure&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This randomized control trial involv 30 premature infants who were randomly assigned into control &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#41; and intervention &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#41; groups using parallel design&#46; Infants in the intervention group received pacifier and swaddling when they were undergoing invasive procedures&#46; The outcome indicators of the two-day intervention were pain score&#44; hearth rate&#44; and oxygen saturation&#46; The Premature Infant Pain Profile &#40;PIPP&#41; was used in this study to measure infants&#8217; pain&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The paired t-test results showed that the pain score and heart rate were significantly increased following the procedure in the control group &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;013 &#60; 0&#46;05&#41;&#59; meanwhile&#44; there was no significant increase in the intervention group &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;256&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;783 &#62; 0&#46;005&#41;&#46; There was no significant different in oxygen saturation in the control group &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;270&#41; and in the intervention &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;370&#41; group before and after the procedure&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Providing pacifier and swaddling can impede the increase of premature infants&#8217; pain score and hearth rate during an invasive procedures&#44; therefore it can be implemented as an alternative to pain management in premature infants&#46;</p></span>"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Difference&#58; the result from mean after invasive procedure minus mean before invasive procedure&#46; Between groups&#58; the comparison of mean differences between intervention and control groups&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Measurement indicator&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Within group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Between group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">t &#40;p&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">t &#40;p&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " colspan="6" align="left" valign="top"><span class="elsevierStyleBold">Pain score</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Intervention</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Before&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;93<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;81 &#40;0&#46;783&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>After&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Difference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Control</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Before&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;40<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;56 &#40;0&#46;003&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>After&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Difference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;2&#46;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;00 &#40;0&#46;056&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " colspan="6" align="left" valign="top"><span class="elsevierStyleBold">Hearth rate</span></td>  </tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Intervention</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Before&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">139&#46;40<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;69&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>After&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">144&#46;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#46;19&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Before&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">149&#46;63<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;45&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>After&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">158&#46;57<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#46;90&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Before&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&#46;80<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 11308621
Original language: English

DOI:10.1016/S1130-8621(18)30035-4

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Year/Month	Html	Pdf	Total

2024 October	34	3	37
2024 September	52	18	70
2024 August	37	14	51
2024 July	23	8	31
2024 June	25	11	36
2024 May	35	11	46
2024 April	39	10	49
2024 March	57	17	74
2024 February	42	1	43
2024 January	55	4	59
2023 December	67	9	76
2023 November	70	8	78
2023 October	101	14	115
2023 September	53	1	54
2023 August	46	5	51
2023 July	58	3	61
2023 June	43	6	49
2023 May	49	7	56
2023 April	52	6	58
2023 March	41	3	44
2023 February	50	12	62
2023 January	45	7	52
2022 December	54	5	59
2022 November	59	9	68
2022 October	42	8	50
2022 September	39	7	46
2022 August	33	6	39
2022 July	36	19	55
2022 June	32	10	42
2022 May	54	15	69
2022 April	41	20	61
2022 March	41	13	54
2022 February	33	10	43
2022 January	67	9	76
2021 December	60	18	78
2021 November	45	18	63
2021 October	69	21	90
2021 September	58	19	77
2021 August	37	15	52
2021 July	20	10	30
2021 June	30	7	37
2021 May	44	13	57
2021 April	116	17	133
2021 March	93	29	122
2021 February	51	15	66
2021 January	46	15	61
2020 December	52	13	65
2020 November	66	24	90
2020 October	31	16	47
2020 September	38	23	61
2020 August	46	11	57
2020 July	37	15	52
2020 June	38	22	60
2020 May	35	14	49
2020 April	46	9	55
2020 March	21	7	28
2020 February	45	13	58
2020 January	52	26	78
2019 December	35	16	51
2019 November	50	21	71
2019 October	65	19	84
2019 September	51	9	60
2019 August	35	13	48
2019 July	39	12	51
2019 June	47	23	70
2019 May	123	34	157
2019 April	89	6	95
2019 March	17	2	19
2019 February	1	0	1
2018 December	12	7	19
2018 November	1	0	1
2018 April	1	0	1

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