Effects of Smelling Amniotic Fluid on Pain and Stress in Preterm Infants During Cannulation

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O R I G I N A L A R T I C L E

Effects of smelling amniotic fluid on preterm infant's pain and stress during peripheral cannulation: A randomized controlled trial

Dilek Küçük Alemdar

¹

| Fatma Güdücü Tüfekci

²

1Nursing Department, Faculty of Health Sciences, Ordu University, Ordu, Turkey

2Pediatric Nursing Department, Nursing Faculty, Ataturk University, Erzurum, Turkey

Correspondence

Dilek K. Alemdar, Nursing Department, Faculty of Health Sciences, Ordu University, Ordu 52200, Turkey.

Email: [email protected]

Fatma G. Tüfekci, Pediatric Nursing Department, Nursing Faculty, Ataturk University, Erzurum 25240, Turkey.

Email: [email protected]

Funding information

The Scientific Research Projects (SRP) of Management Unit of Giresun University, Grant/Award Number: SAĞ-BAP-A- 2014-42

Abstract

Aim: To investigate the effect of smelling amniotic fluid on preterm infants' pain and stress caused by peripheral cannulation.

Methods:This was a randomized controlled trial. The study sample consisted of 80 preterm infants meeting the case selection criteria and infants were randomly assigned to each group. However, in addition to the infants excluded from the study, total number of the infants in all the groups was 61. Infants in the amniotic fluid group smelled amniotic fluid for 15 min before, during, and after the application of peripheral cannulation while those in the control group received routine care during the procedure. The Premature Infant Pain Profile was used to assess their pain levels, and salivary cortisol analysis was performed to evaluate stress levels.

Results:Preterm infants in the amniotic fluid and control groups had similar baseline characteristics. However, the pain levels of infants in the amniotic fluid group were significantly lower than of those in the control group during and after the procedure. After the procedure, cortisol levels of the infants in the amniotic fluid group were lower than of those in the control group, although this difference was not significant.

Conclusion:The intervention of smelling amniotic fluid is a practice that can be used for reducing pain and stress of preterm infants during peripheral cannulation.

K E Y W O R D S

amniotic fluid smell, pain, peripheral cannulation, preterm infants, stress

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I N T R O D U C T I O N

Premature infants who have to spend the first week of their lives at the neonatal intensive care unit (NICU) experience pain and stress due to countless and various reasons. They are exposed to numerous painful interventions without analgesia (Dinçer, Yurtçu, & Günel, 2011;

Ovalı & Dagoglu, 2007). The pain felt by newborns can adversely affect the clinical course of the disease,

behaviors of the infant, his/her adaption to the outside world, development of brain and emotions and infant- family interactions. In order to decrease these effects, the pain should be identified accurately and the time and factors causing pain should be minimized (Anand, 2007;

Dinçer et al., 2011).

Olfactory (smell) system is a special system maturing quite early in the development of sense, with strong nutrition ties, and the mother-infant attachment

DOI: 10.1111/jjns.12317

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(Goubet, Rattaz, Pierrat, Bullinger, & Lequien, 2003;

Goubet, Strasbaugh, & Chesney, 2007; Rattaz, Goubet, &

Bullinger, 2005).^,The sense of smell is responsible for the formation of many motor and emotional responses in the brain (Lutes, Graves, & Jorgensen, 2004). It is known that bad odors reduce positive responses and fragrances increase the positive responses in babies (Marlier, Schaal, Gaugler, & Messer, 2001). Infants are not only able to tell the difference between the maternal and nonmaternal breast, milk, neck, and axillary odors the first few days after being born, but they also show a preference to orient toward their mother's amniotic fluid, which is an odor that they have come into contact with prenatally through the mother's diet and when it has been treated with her amniotic fluid (Marlier et al., 2001; Varendi, Porter, & Winberg, 1997). This preference for odors to the maternal amniotic fluid has clear adaptive qualities in terms of ensuring efficiency in nursing (Varendi, Porter, & Winberg, 1994).

Babies are exposed to many negative stimuli such as strong perfumes or scented cologne, alcohol, cleaning chemicals, alcohol-based hand rubs, and oral medica- tions in the NICU. These odors should be reduced or counterweight fragrances established, with a positive stimuli, such as breastfeeding or parent-smelling sub- stances (Lutes et al., 2004; Yıldız, Arıkan, Gözüm, Tas¸tekin, & Budancamanak, 2011). Thus, negative physiological reactions in infants are decreased, they develop a sense of security, and the development of the bond between babies and parents is easier. However, there is the likelihood of experiencing negative odors. For exam- ple, if the baby receives a constant smell of alcohol during the blood collection process, will then expect a painful process when faced with the smell of alcohol and begin to cry (Hennessy, 2004; Lutes et al., 2004).

Biochemical symptoms can be used as an objective method in following up pain and stress in newborns. Bio- chemical symptoms of stress and pain in newborns include release of hormones such as cortisol, epineph- rine, norepinephrine, growth hormone, and endorphins (Calixto, Martinez, Jorge, Moreira, & Martinelli, 2002;

Chou, Lien, Lin, Fu, & Kao, 2011; Harrison, Johnston, Spence, Gillies, & Nagy, 2005; Mitchell, Chang, Yates, &

Hall, 2012; Neu, Goldstein, Gao, & Laundenslager, 2007;

Peters, 2001; Ramsay & Lewis, 2003). One of the most fre- quently tested stress hormones in newborns among them is cortisol. Due to the fact that taking blood samples for analysis of serum cortisol levels is a painful procedure, it brings a restriction in assessment of pain and stress. It is shown that there is a high positive correlation between serum cortisol level, an invasive method, and salivary cortisol analysis, a non-invasive method. Salivary cortisol analysis was used to evaluate the efficacy of interventions aiming to reduce the pain and stress in newborns

(Felt et al., 2000; Gitau et al., 2009; Grunau et al., 2010;

Mörelius, Theodorsson, & Nelson, 2005; Nelson, Arbring, & Theodorsson, 2001; Takahashi, Tamakoshi, Matsushima, & Kawabe, 2011; White-Traut, Schwertz, McFarlin, & Kogan, 2009).

No study evaluating the effect of smell of amniotic fluid, which is thought to be useful for decreasing the pain developing during peripheral cannulation in premature infants, has been found. The practices to be implemented in accordance with the results obtained from these interventions are thought to be supportive for care of premature infants. This randomized controlled trial was conducted to evaluate the effect of smell of amniotic fluid on pain and stress in premature infants receiving treatment and care at an NICU during peripheral cannulation.

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M E T H O D S

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Design and sample

This was a randomized controlled trial. The study popu- lation consisted of preterm infants who received treatment and care in the NICU, between June 2014 and October 2015. The study sample consisted of 80 preterm infants meeting the case selection criteria and infants were randomly assigned to each group. However, due to the infants excluded from the study, total number of the infants in all the groups was 61 (30 infants in amniotic fluid group and 31 infants in control group) (Figure 1).

As a result of post hoc power analysis, the power was determined as .88 with the risk ofβ= .20 andα= .05 at significance level of .05 for 61 preterm infants. The order of the groups was determined by randomization. Ran- domization was performed using a computer program.

Selection criteria of research group: 28–36 weeks gestational age (according to Premature Infant Pain Profile [PIPP] guidelines used to assess pain, gestational age of infants must be between 28 and 36 week); 1000 g and more weight; health status is stable after 24 hr of birth;

no congenital anomalies; cesarean section with epidural and spinal anesthesia; no enteral nutrition; no blood and meconium mix to amniotic fluid during a cesarean section (it may change the amniotic fluid smell).

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Study hypotheses

Hypothesis 1 Making premature infants smell amniotic fluid reduces pain induced by peripheral cannulation.

Hypothesis 2 Making premature infants smell amniotic fluid reduces stress induced by peripheral cannulation.

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Measures

The following forms were used to collect the data: the Preterm Infant Information Form developed by this researcher to record natal and postnatal information about the preterm infant, PIPP to assess the level of pain, and the Cortisol Analysis in Saliva to assess the level of stress.

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Preterm Infant Information Form

This form includes the newborn's age, gender, gestational age, birth weight, length, head circumference, Apgar score, nutritional status, and its diagnoses.

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PIPP

This form was developed by Stevens, Johnston, Pet- ryshen, and Taddio (1996), and its validity study was conducted by Akcan, Yigit, and Atıcı(2009). In this form, the following seven indicators are scored to assess the infant's pain during the procedure: gestational age, behavioral state, maximum heart rate, minimum oxygen saturation, brow bulge, eye squeeze, and nasolabial furrow. Each item is scored between 0 and 3, from the least affected to the most affected by the procedure. According to PIPP guidelines, gestational age must be between 28 and 36 weeks, and behavioral state must be scored depending on the criteria such as active–quiet, awake–sleep, eyes open–closed, and display of any facial movements.

F I G U R E 1 Enrollment flow diagram for preterm infants in pain and stress arm of smelling amniotic fluid study

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Furthermore, increase in the heart rate must be scored in the range of 0–25 beats/min, and decrease in oxygen saturation is assessed between 2.4 and 7.5%/min. The final total score is determined with all the aforementioned parameters to arrive at the infant's pain level score, the highest score being 21 and lowest score being 0. The level of pain is considered mild if the total PIPP score is between 0 and 6 points, moderate if it is between 7 and 12 points, and severe if it is between 13 and 21 points (Akcan et al., 2009; Stevens et al., 1996). The PIPP is rou- tinely used in the NICU where this study is performed.

PIPP evaluations are not blinded because pain evaluation should be made by watching videos. Since gauze sponge placed near noses of infants during evaluation of PIPP in the amniotic fluid group was seen from videos, it was understood in which group they were involved.

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Cortisol analysis in saliva

The infants' saliva samples were collected twice in both amniotic fluid group and control group. One sample was collected just prior to peripheral cannulation and the other was collected 20 min after completion of the cannulation. The two collection times were 25 min apart because peak cortisol responses can be captured 20–30 min post-pain stimulus (Cignacco, Denhaerynck, Nelle, Buhrer, &

Engberg, 2009; Cong, Ludington-Hoe, & Walsh, 2011;

Herrington, Olomu, & Geller, 2004). Because all cortisol sampling began at the same time in the morning, the influence of the pulsatile secretion of cortisol, which dis- plays a circadian rhythm in preterm infants (Cong et al., 2011; De Weerth, Zijl, & Buitelaar, 2003; Neu et al., 2007), was controlled. The infants were not fed before collection of saliva samples (Cong et al., 2011). Collecting saliva samples from preterm infants for analysis of salivary cortisol by using soft cotton swab is relatively easy.

The soft cotton swab was gently placed in the infant's buccal and sublingual space where it remained for 3–4 min to absorb saliva. Salivary cortisol levels were determined using Salimetrics Salivary Cortisol Kit. Corti- sol samples were analyzed in an accredited laboratory by using standard procedures.

A high correlation was determined between plasma cortisol and salivary cortisol in evaluation of stress in preterm infants. The normal values of salivary cortisol in preterm infants were not exactly determined; however, it was determined that average gestational age was between 30.6 weeks and ±1.9 weeks and salivary cortisol levels were 2.6μg/dL on average in the study conducted with 48 newborns whose birth weights were between 1,085

±252.7 g (Calixto et al., 2002). Serum cortisol reference range was between 3.99 and 26.97μg/dL for the

premature infants born in the 24th week and between 2.39 and 16.1μg/dL for the infants born in the 29th week.

It was determined that cortisol level increased during painful interventions in premature infants and decreased with relaxing interventions such as massage and kangaroo care (Herrington et al., 2004; Mörelius et al., 2005).

Cortisol increases with stress response and is used as an indicator of clinical intervention efficiency in premature infants (Elverson & Wilson, 2005).

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Data collection

All venipuncture procedures were performed by the same nurse working on the day shift (who had 5 years of NICU experience). Any pharmacological or non-pharmacological pain relieving methods is not applied to infants under peripheral cannulation in NICU where the study was conducted.

All the factors that could affect the pain level of preterm infants in amniotic fluid and control groups during the practice were standardized. These factors were that the procedure was administered while the preterm infant was not crying;

and if he/she was crying, it was delayed for 2 min. Also, infants were awake before the procedure. Cephalic and basilic veins were used in all premature infants during the procedure. Before the procedure, the area was cleaned from the center to periphery by using 70% alcohol in all premature infants for skin antiseptic. The procedure was performed after waiting for at least 30 s. Yellow catheter no: 24 was used in the procedure. A cannula needle was inserted in the tissue at 15–20angle. Thus, veins were accessed by simultaneously penetrating the skin and the vein. After being sure that the needle was in the vein, catheters were fixed on the skin by using transparent plaster. To evaluate the environmental conditions in the NICU, light and noise levels were recorded every morning (09:00 hours), respectively, in lux using a pho- tometer and dBA using sound meters. The environment outside the incubator had similar properties for all infants: room temperature of 24–25C (min-max), ambient light of the 92–115 lx (min-max), and the sound quantities of 48–82 db (min-max). The interventions applied to the preterm infants in the control and amniotic fluid groups of the study are as follows.

The preterm infants in the amniotic fluid group were made smell their own mothers' amniotic fluid: 8–10 cc of amniotic fluid was taken by the doctor into a 20 mL injector during cesarean section and kept at 8C in the refrigerator until cannulation administration. In premature infants hospitalized at the NICU, amniotic fluid was fixed 5 cm away from the infants' noses by pouring it on a big piece of sterilized gauze sponge 15 min before peripheral cannulation. The infants were made smell amniotic fluid during the procedure and up to 15 min

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after the procedure. Images of the baby before, during and after procedure were record by video recorder. The video recording was made by the researcher. Saliva samples were taken from the infants 5 min before and 15–20 min after the peripheral cannulation. Peripheral cannulation was performed by clinical routine for premature babies in the control group. Images of the baby in before, during and after procedure were record on the video recorder.

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Ethical considerations

To conduct this study, we obtained the legal permission from the institution with an ethical consent form from the Atatürk University Health Science Faculty Ethics Commit- tee. We explained the purpose of this study to the families of the premature infants who were included in this study and answered their questions. Written informed consents were obtained from the parents of the infants. Parents were assured that the information they gave would be confiden- tial and would not be used anywhere else. In this study, we have fulfilled the related ethical principles of informed consent, voluntariness, and privacy protection of the human subjects and upheld the protection of their individual rights.

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Statistical analysis

The researcher viewed the video recordings after the procedures to evaluate the pain. Video recordings for both groups were viewed by two NICU nurses and the researcher after the procedure to evaluate the pain, and the researcher's observations were used for data analysis because there was no statistically significant difference according to the result of the inter-observer agreement test performed both for the pain (Kendall = 0.489,p> .05).

Data were analyzed using the Statistical Package for Social Sciences (SPSS) 18.0 statistical analysis software packages. Percentage distribution, mean value, standard deviation, Chi-square value, Kendall W and t test comparison between groups was used for the statistical analysis of the data.

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R E S U L T S

3.1

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Comparison of descriptive

characteristics of the control and amniotic fluid groups

No statistically significant difference was found between the control and amniotic fluid groups in terms of gender,

gestational age, birth weight, birth height, head circumference, diet, the Apgar score at 1 and 5 min, and diagnosis averages (p> .05; Table 1).

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Comparison of the average PIPP scores between the control and amniotic fluid groups

It was found that pain levels of the infants in the control group were 4.45 ± 1.02 before the procedure, 11.03

± 1.48 during the procedure, and 8.16 ± 2.64 after the procedure. Pain levels of the infants in the amniotic fluid group were determined to be 4.40 ± 1.06 before the procedure, 10.30 ± 1.48 during the procedure, and 5.66

± 1.18 after the procedure. The pain levels of the infants in the amniotic fluid group during and after the procedure were determined to be significantly lower than the infants in the control group (p< .05) (Table 2, Figure 2).

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Comparison of the average cortisol level between the control and amniotic fluid groups

Stress levels of the infants in the control group were determined to be 1.75 ± 1.64μg/dL before the procedure and 3.33 ± 2.15μg/dL after the procedure. Stress levels of the infants in the amniotic fluid group were determined to be 1.47 ± 0.77μg/dL before the procedure and 2.75

± 1.64μg/dL after the procedure. Cortisol levels of the babies in the amniotic fluid group before and after the procedure were determined to be lower than the infants in the control group; however, this difference was not significant (p> .05) (Table 3, Figure 3).

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D I S C U S S I O N

Studies on the short-term effects of pain have shown that pain affects various physiological and behavioral parameters. Regarding physiological parameters, there are increases in cardiac rhythm and plasma cortisol levels, and decreases in oxygen levels. Behavioral activities, such as crying, grimacing and motor activity, are increased.

Using these parameters, soothing and analgesic methods have been developed such as nonnutritive suckling, sucrose, skin-to-skin contact, and breast feeding (Gray, Watt, & Blass, 2000; Johnston et al., 2002). This olfactory preference for odors linked to the maternal environment has obvious adaptive qualities for efficient nursing. The fetus ingests the smell of amniotic fluid in the intrauter- ine period and this smell constitutes a chemical stimulus

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T A B L E 1 Comparison of descriptive characteristics of the control and amniotic fluid groups (N = 61)

Characteristics

Groups

X²ortvalue pvalue Control (n = 31) Amniotic fluid (n = 30)

n (%) or mean ± SD n (%) or mean ± SD Gender^a

Girl 13 (41.9) 10 (33.3) 0.16 .32

Boy 18 (58.1) 20 (66.7)

Diagnosis^a

RDS 27 (87.1) 28 (93.3) 1.10 .19

RDS + FGR 4 (12.9) 2 (6.7)

Gestational ages^b 33.90 ± 3.17 31.30 ± 2.57 0.73 .43

Birth weight (gr)^b 2,299.03 ± 758.21 1,734.73 ± 599.04 1.24 .87

Birth head circumference (cm)^b 32.27 ± 4.18 29.95 ± 3.03 0.89 .92

Birth height (cm)^b 45.67 ± 5.12 41.95 ± 4.44 1.45 .78

Median ± IQR Median ± IQR KSz pvalue

Apgar score 1^c 5.80 ± 2.00 4.60 ± 2.01 1.87 .54

Apgar score 5^c 7.54 ± 1.43 6.80 ± 1.21 1.65 .36

Abbreviations: FGR, fetal growth restriction; IQR, interquartile range; RDS, respiratory distress syndrome; SD, standard deviation.

aChi-square.

bTwo independent samplettest.

cKSz, Kolmogorov–SmirnovZtest.

T A B L E 2 Comparison of the average PIPP scores between the control and amniotic fluid groups

PIPP

Groups

Control (n = 31)^a Amniotic fluid (n = 30)^a

tvalue pvalue

Mean ± SD Mean ± SD

Before peripheral Cannulation 4.45 ± 1.02 4.40 ± 1.06 0.08 .84

During peripheral Cannulation 11.03 ± 2.71 10.30 ± 1.48 6.67 .01

After peripheral Cannulation 8.16 ± 2.64 5.66 ± 1.18 4.70 .03

Abbreviations: PIPP, Premature Infant Pain Profile; SD, standard deviation.

aTwo independent samplettests.

0 2 4 6 8 10 12

Before Peripheral Cannulation

During Peripheral Cannulation

After Peripheral Cannulation Amniotic Mai Group Control Group

F I G U R E 2 Changes in Premature Infant Pain Profile (PIPP) score from before peripheral cannulation to after peripheral cannulation

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for him/her. It is observed that this smell helps the baby to become calm and adapt to new environments in the newborn period (Varendi, Christensson, Porter, &

Winberg, 1998).

In this study, PIPP scores of newborns before, during and after peripheral cannulation were compared; PIPP score of the newborns made to smell amniotic fluid was determined to be lower than those in the control group before and after the procedure (p< .05). In the literature it is stated that smells related to mothers represent trust and decrease pain and stress of the newborns (Goubet et al., 2007;

Nishitani et al., 2009; Rattaz et al., 2005; Sullivan & Toubas, 1998; Varendi et al., 1998). These studies support our results.

Infants are not only able to tell the difference between the maternal and nonmaternal breast, milk, neck, and axillary odors the first few days after being born, but they also show a preference to orient toward their mother's amniotic fluid, which is an odor that they have come into contact with prenatally through the mother's diet (Schaal, Marlier, & Soussignan, 1998; Schaal, Marlier, &

Soussignan, 2000) and their mother's breast when it has been treated with her amniotic fluid (Varendi et al., 1997). This preference for odors related to the maternal environment has clear adaptive qualities in terms of

ensuring efficiency in nursing (Varendi et al., 1994). In their study, Varendi et al. (1998) observed that newborns smelling amniotic fluid cried for shorter time than those in breast milk smell and control groups. In another study that analyzed the effect of smells on pain, it was determined that crying infants were made to smell a cloth of their mothers, a cloth of another mother, and a cloth never used and they gave more positive responses to the smells of their own mothers. (Sullivan & Toubas, 1998).

In their study, Rattaz et al. (2005) determined that smells of breast milk and vanilla during heel lance decreased grimaces of newborns and only smell of breast milk was effective in decreasing the neonatal stress after heel lance. In their study, Goubet et al. (2007) stated that the newborns who were made smell familiar scents during heel lance cried 32% less than those in the control group and the group which was made smell vanilla. In the studies conducted concerning heel lance, it was determined that the newborns smelling their own mothers' breast milk felt significantly less pain and showed less uneasi- ness/agitation (Nishitani et al., 2009; Rattaz et al., 2005).

In a study conducted by Marlier, Gaugler, and Messer (2005) it was stated that smell stimulation decreased apnea frequency and severity. In their study, Goubet T A B L E 3 Comparison of the average cortisol level between the control and amniotic fluid groups

Salivary cortisol (μg/dL)

Groups

tvalue pvalue Control (n = 31) Amniotic fluid (n = 30)

Mean ± SD Mean ± SD

Before peripheral cannulation 1.75 ± 1.64 1.47 ± 0.77 0.47 .96

After peripheral cannulation 3.33 ± 2.15 2.75 ± 1.64 1.44 .20

Abbreviations: SD, standard deviation.

Two independent samplettests.

0 0.5 1 1.5 2 2.5 3 3.5

Before Peripheral Cannulation

After Peripheral Cannulation

Salivary Cortisol Means (μg/dL)

Control Group Amniotic Mai Group F I G U R E 3 Changes in salivary

cortisol means (μg/dL) from before peripheral cannulation to after peripheral cannulation

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et al. (2003) stated that as a result of giving vanilla smell to newborns during heel lance and venous blood-letting, giving perfume scent for the first time and giving no scent they determined that the newborns given a familiar scent cried and grimaced less. This study and previous studies indicate that making newborns smell scents of their mothers is an effective method for relieving the interventional pain of newborns. The studies examining the effect of scents on pain support results of the present study (Goubet et al., 2007; Kane et al., 2004; Nishitani et al., 2009; Rattaz et al., 2005; Sullivan & Toubas, 1998;

Varendi et al., 1998).

As a result of the present study, a significant difference was determined in cortisol values before and after the procedure in amniotic fluid and control groups. In a number of studies, salivary cortisol analysis is determined to be a valid method to measure pain and stress in newborns. In the present study, it was observed that salivary cortisol value increased after painful interventions. In their study, Nishitani et al. (2009) determined that the mean of salivary cortisol value for the control group was 11.7 nmol/L before heel-stick and 25.6 nmol/L after heel- stick. The mean salivary cortisol value for the own mother's breast milk odor group was 19.0 nmol/L before heel-stick and 20.7 nmol/L after heel-stick. Paired t test revealed a significant increase in salivary cortisol levels after heel-sticks compared to those before heel-sticks in the control group, but not in own mother's breast milk odor group. Mörelius, Carlen, Norman, Hellstrom- Westas, and Nelson (2006) stated a significant increase in salivary cortisol, PIPP and neonatal infant pain scale values of premature and full-term babies during and 30 min after diaper change and this increase was stated to be higher in premature infants.

Kawakami et al. (1997) stated that making newborns smell breast milk of another mother and lavender scent during heel lance did not decrease the crying time; however, it contributed to decrease of cortisol values. In some studies, a low correlation between salivary cortisol and pain of newborns in the painful intervention was determined (Greenberg, 2002; Harrison et al., 2005;

Herrington et al., 2004; Joyce, Keck, & Gerkensmeyer, 2001). They showed that this was associated with the inefficient method used for analysis of saliva and con- tamination with milk as a result of enteral feeding.

Saliva samples were taken from all the premature infants in the present study prior to feeding.

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L I M I T A T I O N S

The most important limitation of the study is the fact that amniotic fluid can be obtained only from the infants born

by cesarean section and it is difficult to obtain this fluid at normal birth.

Amniotic fluids can be taken by the doctor into a injector during cesarean section. In the preterm infants hospitalized in the NICU, amniotic fluid was fixed 5 cm away from the infants' noses by pouring it onto a big piece of sterilized gauze sponge. The remaining amount of amniotic fluid may be kept at 8C in the refrigerator and can be used for subsequent painful interventions.

Another limitation is no blinding because pain evaluation should be made by watching videos. Since gauze sponge placed near noses of infants during evaluation of PIPP of the amniotic fluid group was seen from videos, it was understood in which group they were watching.

However, video recordings for both groups were viewed independently by two NICU nurses, (not involved in the research), and the principal researcher (DKA) after the procedure to evaluate the pain, and the researcher's observations were used for data analysis because there was no statistically significant difference according to the result of the inter-observer agreement test performed both for the pain (Kendall = 0.489,p> .05). In addition, taking samples of salvia from preterm infants is a hard procedure. Also, 16 samples were not used due to inadequate amount of saliva. Inadequate saliva volume for the assay, the most common cause of sample loss, may be directly related to the type of assay chosen to measure cortisol as different assays require different amounts of sample. Studies that use assays that require smaller vol- umes are less likely to lose samples due to inadequate saliva volume.

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C O N C L U S I O N

The prevention of procedural pain in neonates should be the goal of all caregivers. Although there is various research on individualized developmental care practices, still there is a need for research to evaluate the impact of initiatives to reduce the environmental odor, light and sounds for preterm infants exposed to painful procedures in NICU. The individualized developmental care practices that will be performed in line with the results obtained from these interventions are thought to be pos- sibly supportive for the care of premature infants. In accordance with these results, smelling the amniotic fluid in pain management of preterm infants, which is among the limitations of the study, can be recommended as an effective method to be used in nursing care practices.

This study evaluated the effect of interventional pain in premature infants by using a biochemical method. The efficiency of biochemical symptoms in following up pain and stress in newborns can be evaluated as an objective

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method for other painful interventions. In the present study conducted with the aim of evaluating the effect of amniotic fluid smell on peripheral cannulation-induced pain in premature infants, PIPP score of the amniotic fluid group during and after the procedure was determined to be significantly lower than the control group;

however, no significant difference was determined between cortisol levels.

A C K N O W L E D G M E N T S

The content has not been published or submitted for pub- lication elsewhere. The study was presented as an oral presentation at the 5th National and 2nd International Mediterranean Pediatric Nursing Congress on November 15–18, 2015 at Ankara-Turkey. Also this research was awarded“Award of the Best Oral Presentation”.

D I S C L O S U R E O F I N T E R E S T S The authors declare no conflict of interest.

A U T H O R C O N T R I B U T I O N

D.K.A. and F.G.T. contributed to the conception and design of this study, D.K.A. carried out the data collection, D.K.A. and F.G.T. conducted the statistical analysis, drafted the manuscript, and read and approved the final manuscript.

O R C I D

Dilek Küçük Alemdar https://orcid.org/0000-0002-7275- 0666

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How to cite this article:Alemdar DK,

Tüfekci FG. Effects of smelling amniotic fluid on preterm infant's pain and stress during peripheral cannulation: A randomized controlled trial.Jpn J Nurs Sci. 2020;17:e12317.https://doi.org/10.1111/

jjns.12317