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NOnpharmac010gical Techniques tO
Redice Pain in Preterln lnfants WhO
Rteceive Heel″ Lance PFOCedure:
A Rand6mized COntr61led Tri五 1
Piera Bこ rgomi,RN

Michele chieppi;LBR
AntOnさ lla Maini,IRN‐ ￨Tlziana MugnOs,RN,Debora.s,ё tti,RN
ChrisOu1le Tを ialla,MD
Luigia Scudё lleち
撃CCS Pο LcL・ icO Stt Ma,

MD。Fο zttα,Pψれ,ItabIntroduc● 011 Thё heel‑lancc(HLl rncthod fOr b100d cOllectiOn from thё
iS COntrOversial for thё

newbompain it causes.This is the arst randomized contrOned t五alon the m,nagement and reduction ofpain using the rnusic Of、 ヽ「
olfgang AmadeuS

MOZart(′ ′SO,ata K.448′ ′)in premature infants hospitali2ed in a neonatalintcnsive

CttrC unit(NICU):ThiS Study has cOmparOd nonphallllaco10gical techniques、 減thstandard pFOCedure for reducing pain during HL procedure.Methods:Thirty― flve
premlture infants were enrolled′cach for 3 HL procedures,Ofwhich each was ran―domizedto 1 0fthe3studyallls AlllswerethenCompattdintell18ofthePrematurelnfant Pain Pr9flle(PIPP)Changes by analysis of variancc(ANOVA).Results:one
hundred ive HL procedures were availableゃ r analysis(35 standard procё dure′
35 music′ 35 gluco,c).Median baselinc PIPP was 3′
and rnedian PIPP after the HL
procedure、 ″as 5.PIPP scale changc was+3 in the contr01 arln′ +l in the glucose
arrn′ +2 in the music arln(ρ = 008)II)iSCllSSiOn:BOth glЧ
cose and lnusic were
safe and effective in lirniting pain increaseヽへ′
hen compared to standard procedure

in HL procedures in pretenn infants.

KeywOrds:pain,musici glucose,infant premature

R『窟』
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335

６
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つク

Bα tt gial.
hc hecl― lance(HL)rnethOd fOr blood collection from the newbom is contro―

such asbnlisingofthepuncturesite and innarnmatiOn strtanen′ Felhnan,Brorrmels′&V五 nikka,2001).Venipuncture is preferred becausc it is less paini」 and lnore
cffective(LagO et al.′ 2009,Ⅳ 10rrow′ Hidinger′ &ヽVilkinson― Faulk′ 2010)′ but HL iS
versial for the pain it causes and an increased risk of skin lesions′

often the only viable option for a blood collection in the care of pretellllinfants̲
Preterm infants have the capacity to feel pain at birth′ and this can have adverse
short― and long― ternl effects fronl pain(Fitzgerald′

1991;JOhnstOn′ Fernandes,&Campbell― Yeo′ 2011).The pain related、 rith hecl lancing is closely associated llvlth〜

squcezing ofthe heel rather than breaking ofthe skin via the heel prick(L4orrOWet al.′ 2010).Squcezing

is itself a cause ofpointless pain(LagO ct al.′over′ the development ofthe neⅣ2009),Inore¨

ous system is extremely vulnerable to peripherallesions(Fitzgerald′ 1991).The existing guidelines for the management of pain in
もorns(LagO et al.′ 2009,Spence ct al.′ 2010,Vani′ 2011)suggest several strate―ne、 ャgies to reduce pain in this setting′ including environmental′ pharmacological′

andnonpharmacological measures.

電 NTIONS TO REDUCENONPHARNIACOLOGICALINTEI●PAIN IN PRETE鳳 〔lNFANTS DURING IIEEL Lぶ CE
The use ofnonpharlnacologicaltechniques forpain control、げaspoorin all European

countrics′ although it shovlred a routinc usc of paciners and sucrose solutions inmost European neonatalintensive careunits(NICUS)eXCeptin Spain and the United
Kingdomipositioning and、 waps are used primarilyin Scandinavia′ the Nethenands′
and Belgium.Procedures not sPcciflCally recornrnended by the guidelines are often
usedi for example′ warrning ofthe heel(often in Denmark and Spain)and the use
and eutectic rnixture ofoflocal anesthetics(lidOCaine 2.50/O and prilocaine 2.5%)′
local anestetics cream (in France and ltaly,Losacco et al.22011).SO′ despite thetools provided by the scientiflc literaturef there are signiflcant differences in theclinical practice ofvarious NICU′ the ability to prevent and treat neonatal pain has

nOtiFnprOVed along with the ability to recognize and rncasure it.

Focusing on nonpharrnacological measures,the use of oralsucrosc and non―nutritive sucking(NNS)or human milk iS suggested or′ alternativel)り glucoscusc(Lago et al.′ 2009;Okan,Coban′ Incc′ Yapici′ &L Can′ 2007).A/1ultiple dosesof glucose/sucrose(2 nlin irnmediately before and 2 rnin after the HL)appear
more effective than a single dosc(LagO ct al.′ 2009).NNS sCemsto have a syn―ergistic effect with the sweet taste′ and it iS recommended 171t/heneVer possible(LagO ct al.′ 2009).

THE USE OF NIIUSIc
Another nonpharinacologicalintervention used to reducepain in prematre infants
is listening to music.The human fetus can hear fron1 29 M′ ceks of gestation andhas the ab面 ty to understand and remember auditory stimuli already in the womb
σOhnStOn et al.′ 2011).AcCOrding to neurophysiological studies′ infants PcrCeives、aCο ξcal■ Ch■ jqzcs ιοRcdttcc Pat■

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337

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sirnple and repetitive sounds cOmposed ofindividual sounds(De Battistini′
Rocchi′ 2007)and are tuned tO cOnsonant patterns′

2011,
melodic as well as harmonic′

and to metric rhythms lTrehub′ 2001).Live music can distractthe infant/child during

painful procedures and signiflcantly reduce pain and stress(Kemper&L Danhauer′
2005).A meta― analysis Ofnine randornized trials has sho、 、/n that music can have asigniflcant clinical beneflt for preterrn infants in the NICUs(OISOn′ 1998,Standley72011)′ althOugh studics v√ ith more rigorous approach could provide further conflr―

mation σohnStOn et al.′ 2011).The rnusic v√ orks by dccreasing the state ofarousal
and behavioral responsc(the facial expressiOns Ofpain)during painful procedures(Cignacco et al.′2007).It haS becn proven that FnuSiC has positive cffects in thelong― ternl variables such as weight gain related to the reduction ofenergy usc atrest

and reduction in hospitalizatiOn(Ancora′ 2010).A study by Kemper and Danhaucr(2005)′ who recognized that the music plays a vital role in all cultures and has adirect or indirect role in the phb/si010〔V and clinical symptoms′ notes that′ a■ erhaving becn carefully selected′ it can reduce stress and offers distraction from thepain The resultis the improvement of clinical performance.

The music、 νas in fact able to reduce the hcart rate,salivary cortisOl levels′and the behavior of distress′ and to improve the oxygen saturation′ NNS′ and theincrease in body、veight by reducing the duration of hospitalization(Arnon′ 2011,
Arnon et al.′ 2006).The Same studics have exarnined the short― term effect ofmusic(in parLiCular live music)therapy on variables such as heart rate′

respiratory rate′

blood pressure′ oxygenatiOn′ and pain behavioralstatus on preterrn infants(Arlllon′

2011;Anon etal.′ 2006).
/SOnα″ lin D Mげ
or/Or■

οPlic120s β(イ イの 〃b」 /予 陶 捨 αr2g/ヒnα グbus ifOzα.′

In

the 1990s′ some studies discussed(Chabris′

1999;Ⅳ IcLachlan′ 1993,Rauscher′
Shaゃ vL&q=1993,Steele et al.′ 1999)and Other used(Nantais̀t schenenberg′ 1999;
Newman et al.′ 1995)the″ SOnata in D Maior fOr nvO Pianos(K.448)″ bywOltang′
Arnadeus Ⅳlozart and the relatively、 へ′
ell― knov,「 n″ 九
4ozart effect′ ;in PartiCular′
one study shovlred that expOsure to ⅣIOzart′ s rnusic signiflcantly reduced energy
consumption at rest in stable preterm infants(Lubetzky ct al′ 2010).The MOzart
effect refers to an enhancement Of perforrnance or change in ncurophysiologicalactivity associated with listening to MOzart's musical auditow Stimulation(Valenti
et al.′ 2012).The Selection of music was based on studics that sho、 へ′
ed the A/1ozart
effect efflcient in reducing stress′ pain′ depression′ and anxiety(da SilVa′

Cagao′Marques′ &Merey7 2013,Lubetzky ct al.′ 2010,Pignatta′ 2012).Thc infant
hospitalized in the NICU may be routinely expOsed to noise bet、 ecn 55 and 70 dB
Silva′

A′(Arnon′ 2011)uptO a maximum Of75 dB(Gooding′ 2010)One study by Lubetzk3/

et al.(2010)haS tested the rnusic Of A/1ozart present on compact disc(cD)′rnaking
according tO the American Academy of Pediatrics recom―
mendations′ M′ hich notto exceed volume of 75 dB(Lubetzky ct al.′ 2010).
Strong evidence aboutthe type Ofmusic tO be used islacking,in fact′ the choicc
ofthe type ofrnusic vνras a difncultissuc in the design Phasc.several studies havelisten iorn 65 to 70 dB′

exanlined the effects Of different fOrrns of music including instrumental and vocal

music(Evans′ 2002,Hartling et al.′ 2009,Hodges,2010)Regardless ofthe tン pe ofmusic′ a positive effect on pain response、 へ′
as recorded′ but direct comparison of

りpeS Of music is difflcult(standley7 2002).

Bcrgomi ct滅

338.

Irnportantlyr SOme precautions should be used Mふ en using musiC aS a painfre―
vention rncasure in the NICU.First′ itiS important to consider the leve1 0f matunty
Of the child′ the health′ and indiViduality of their responses to sumuli(EvanS,2002;
Giuliani′ Poluzzi′ Bcllisario′ &L Bitetti′2005).In addition′ the rnllsic Shodd be heard

for no rnore than 20 1nin to avoid senso理 /oVerload(CaSSiC1 2009:G00ding′2010).

AIMS OF THIS STUDY
We designed this study to assess′ in our context′ the use ofmuSiC as a nonpharma―cological techniquc in comparison、 ″ith the use Of glucosc Or standard Procedure.
Furthermore′ we airned to compare the tilne required to conclude the procedure fOr
cOnectiOn Of blood by HL procedure and asseSS potential differences in responSeaccordingto gestaionalage′ gender′ en宙ronmentalnoiSe′ andproVenanCeofthebaby

METHODS
Ittcil::壁 ittI:∫ ::7￡ i罵 :::霧 Tよ 」[寧 轟 奪 歴

糧 爵 毛 瓶 霧

NICU thathosts an average of25‑30 nCOnates eaCh day.The main reasons for adrnit¨ν0tance are prematurity and respiratory distress.It is organized into cight bays:tヽ
NICU bays,one baby scPtiCiSOlation in NICU bays′ th7o intermediate care/nlinirnal
therapy bays′ and threc isolation for infectious diScases bays.ThC hOsPital ethicalcommittee was obtained before study entry.lVe have recciVed fOrmal approval
from the institutional reviev√ board(IRB)On April l,201l lprOtOCoi numberi 1571).

ELICIBILITY CRITERIA
The trial included neonates adrnitted to the NICU in the period May to July 2011.
Eligibility criteria were the fo1lowing:・ Age≧ 30ヽ げeeks gestational

O Age≧ 48 hr oflife
ヽ′ritten conscnt ofboth ParCnts
・ ヽ
o The absencc of drug therapy for pain relicf
e AbilitbrtO suCk and swallow present
・ Expected duration of adrnission atleast 5 days
・ Absence ofbrain lesionsirnpairing swallowingisedation and intubation′
sepsis at the tilne oftrcatment

and acute

STUDY DESIGN
A randonlized block study design、 げas used(b10Ck=infant′ unit Ofanalysis:LH:BO&Callaghan′ 2000).Each infantllvas randorniZed to reccive′ in three conSecutive HLprocedures′ glucose suckling(10%SOlution)′ music′ or standard procedure.Each Of

the 35 paticnts completed the three study procedures(35× 3=105 proCedures).

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339

SAMPLE SIZE,RANDOMIZATION,AND PRIMARY END´
Sample size calculations、A′

POINT MEASURE

ere rnade llvith an Ftest for repeated rneasures′ airning at

detccting(With 80%power and alpha crror5%)′ a4‑pointdimerenceinPrematurc lnfant
Pain Pronle(PIPP)betweCn either glucOse Or music and no treatment(with Standard
deviation of3 points).ThiS required 35 infants all undergoingthrec HL′a differenttreatrnent,thesc9υ

each time Ⅵrith
cC Oftreatinents vvithin each infant was randonlized.

Thc PIPP scale has demonstrated rnodcrate internal cOnsistency(o.59‑0.76 item―
total correlations)′

high interrater(α =0.95‑0.97)and intrarater(αreliabiliち みand constructvalidity((libbins ct al.′=0.89‑0.91)

2006).Thc PIPP scale、 ハ′
as developed

and validated for premature infant pain assessment in 1996(Stevens′,Ohnston′

Pctryshen′ &L Taddio′ 1996)′ has been used at the study site since January 2000

(Gibbins ct al.′ 2006)′ and COntinues tO be a reliable and valid rneasure(American
Academy of Pediatrics comrnittee on Fetus and Newborn et al.′ 2006,Stevens′
JOhnStOn′ Taddio′ Gibbins′ &Yamada′ 201o).

Vvre used thc PIPP scale translated into ltalian thatincludes seven indicatorsi threc

beha宙 oralindicatOrs lbrOv√ bulge′ eyesquceze′ nasOlabial furrO、tllVo clinicalindica―り′〜
tOrS ttCa■ rate andoxygensaturauon)′ andtヽ VocOntextindicators lsleep刊√
ake rhythm′
facial expression′ eyes open and c10sed).TO Cach indicator′

a score fron1 0 to 3 11vas

gven,indi17idual scores v√ ere then summed up.A flnal scOrc PIPP≦

6 indicated low

orno pain.A flnal scorc PIPP>12 indicated a rnoderate or high pain(Santullo′2009).

STATISTICAL NIIETHODS
Descriptive statistics、 vere produCed fOr demographic′clinical,and laboratOry

characteristics ofcases.lVIcan andstandard deviatiOn lSD)are presented fornorFnally
distributed variables′ and lnedian and interquartile range(IQR)for nOn―

nOrmally
distributed variables.Thcthrectreatmentsw9recomparedusinganaヶ SiS Ofvariance(ANOVA)in terms Of PIPP scale changes(PIPP after HL FninuS PIPP before HLl andoftime required to concludc the procedure.Ⅳ Iultivariate analyses were performed

私ぇth linear regression.
PIPP score has also been described(WithOut fOrlnal statistical testing)in thefollollving categories:
・ Gestational age(≧ 36 wecks,32‑35もへ′ecks′ 28‑31 wecksi<28、 vecks)
・ GenderO Envlronmental noisel especially impulse sounds(preSence/absencc)
・ Departrnent of origin(NICU/neonat010gy/hOme/Other).

STUDY PROCEDURES
Evecソ datt nurSes screened eligible infants andprOposedparticipation to theparents.

During an intervieL the study aims and procedures were detailed to both parents′
and an information leaflet、 vas left fOr them to read.In a second intenrie、 へ′′v′ rit―ten consent、 げas requcsted frOrn both parents.After obtaining consent′ the infantBergomi ct a.

340

crib was rnarked with the study symbol(an image representing threc infants llvlth
headphones′ with the sentence:Pain?I No thank youI).The randonlization list withso thatreference to cach enrollcd child llvas hung in the nurse coordinator room′each nurse on duty could check which treatment each Child should receive for eachofthe thrce HL proCedures for the study and mark it after the procedure.
In Our hospital′ nursing staffroutinely altemate五 ght and leftheclfor HL′ and in ourstuゥ HLwasperforlnedwithanautomaticlancetoftheTenderfootvanctyratherthana manuallancet′ vЛ thout squeczing the heel(LagO ct al.′ 2009,Shepherd′ Glenesk′
ertanen et al.′ 2001).Tenderfoot is available in fbur sizes
Niven′ &Mackenzie′ 2006,ヽ 石

according to body weittt or age.The HL b100d d⊆ 雨 ng techniquc was made輌 th astandardized technique by expenenced nurses(Ometto′ 2010).Immediately before
staning the HL proCedure(With the mate五 al reaも and befOre touching thc hcel,inthe range iom O to 2 min)and immediately a■ er lwhen the heel was released aierthe HL proccdure′ in the range from O to 2 min)′ pain in the infant was rated with the

PIPP scale.Assessments were made byrescarchers blind to studytreatment′ exceptin
the case ofmusic therapy,in this casc′

pain was rated t、 帆ce byt、 vo different operatorsand the average ttvas used.

Duringtheprocedure′ regardless oftherunningforrn oftreatment,precautionswere
taken to reduce background noisc′ as standard practice to avoid the negative effects ofstress′ andsounds and noises higherthan 70 dB Were completely avoided(Setting thealam五 ngtones to a standard level′ setting the standard五 ngOne ofmobile′ low levelofvoices ofoperators and Parents,Gooding′ 2010).
The baby could exitthis study if discharged′

vish′transferred to NICU′ parents′ ヽor anyother condition which in the opinion ofthe investigatorwOuld compromisc
the health ofthe nev′ born in case ofcOntinuation ofthis stuヽ ̲None ofthe cnrolled
preterm infants dropped out ofthis studb/・

PROCEDURE WITH GLUCOSE・ The nurse delivered 10%glucose l‑2 rn1 2 rnin before starting the procedurel insmall doses over a period of a maxirnum of 2 1nin;if the pretellll infant prior to
ed to continuc.
′sampling llvas suckling the pacifler′ thisヽvas allo、 、・ The nurse identifled the point ofthe hecl(avoiding th9 punCture ifalreadyiniured′scarred′ or bnlised),diSinfectedi grabbed the heel holding it vJlthout squcezing′

pricked h71th a rnanual ncedle,and dried the flrst drop、 vith gauze.

・ The nurse fllled the capillaries necessarybymaking an interrnittentpressure aroundthe tip area.

・ Atthe end ofthe procedure,the nurse adrninistered glucosc l‑2 nllin small doses
for a maxirnurn of 2 1nin.

O A seCOnd nurse rated pain、 へ′
ith thc PIPP SCale′ 2 min before starting and 2 rnin at
the end ofthe procedure.

PROCEDURE WITH Muslc
O Fron■ 5 rnin prior of HL to 5 1nin afterthe drawing and for notlonger than 20 rnin′

the baby was made listen to″ Sonata in D Major forヽ vo Pianos(K.448)″ byV√olfgang Amadcus Mozart(the Sec6nd movement,andantc),The sonata′ lastingNο 71pttm

341

οycα:■ ch71iq2cs tt Rcd2cc Paれ!οvvas repeatedly played fOr a maxilnum tirne of 18 1nin.The speakers

about 8 nlin′、
vere positioned in the same rttom with the cradle/crib Ofthe ne、

νbornithe soundintensity in the pro対 mity tO the newbOm was nota1lowed to excced 65‑70 dB.

・ The nursc identi「 led the point ofthe heel(avoiding the puncture ifalreadyiniured′grabbed thc heel holding it Ⅵ減thout squeezing′
pricked with a rnanual ncedic′ and dried the rlrst drOp with gauze̲
scarred′ or bruised)′ diSinfected′

・ The nurse fllled the capillaries necessarybymaking an interrnittent pressurc aroundthe tip area.

・ A sccond nurse rated pain llvith the PIPP scale′ 2 rnin before starting and 2 nlin at

the cnd ofthe procedure

STANDARD PROCEDURE
・ The nursc identifled the point ofthe hecl(avoiding the puncture ifalreadyiniured′scarredi or brLliSed)′

disinfected′ grabbed the heel holding it、、/ithout squeczing′

pricked with a rnanual needle′ and dried the flrst drop、 へ/ith gauze.

Thenursefllledthecapillanesnecessarybymakinganintellllittentpressurearoundthe tip area.

A second nurse rated pain、 へ√
ith the PIPP scale′ 2 1nin before starting and 2 1ninutes

atthe end ofthe procedure.

RESULTS
Thi町―■Ve infants werc enrolled;24(68.5%)were males′

14(40%)were from thesame hosPital neonatology7 1 came frttm hOme′

and 20、 ハ
ere fronl other hospitals′′
from the delive=yr00m′ or from the pediatric emergency rooln ofthc hospital.The

acceptance diagnosis、 げere respiratOry distress(9′ 25.0%)′ prematurity and respi―
ratOW diStress(14′ 40.0%)′ respiratoヮ distress(3′ 2.6%)′ biliaw atresia(2′ 5.75%)′
clefpalate(2′ 5.75%)′ brOnchiolitis(2,5.75%)′ suSpected scPSiS(1′ 2.820/0)′ 10W birth、reight(1′ 2.820/0)′ and hematochezia(1′ 2.82%).The rnedian gestational age at birth〜
was 34 wccks(IQR 32 37′ min― max range 25■ 1)′ median gestational age at study
entry llvas 37 Vveeks(IQR 34.4‑38.0′ rnin― max range 30‑45)′ and median duration
ofhosPital Stay、 as lo days(IQR 5.5‑25.0′ min― max range 2‑90).
^′

Therefore′ 105 HL were available fbr analysis(35 standard procedurc′ 35 rnusic′
35 glucosc)′ 63(60%)on the right heel Forty― t■vo(40%)HL procedures、ノVere Carriedout with background noisc(moStly lnOnitors and in some cases human voices).
A/1edian bascline PIPP was 3(IQR 2‑3′ rnin― max range O‑8)′ and median PIPP
after the HL procedure llvas 5(IQR 4‑6′ rnin― max rangc o‑14).Comparison ofPIPP
scale changes in the three study arrns is reported in Figure l:A/1edian increase in
PIPP vo「 as 3 pOints(IQR 2‑6)in the COntrol group′group′ and 2 pOints(IQR l‑4)in the rnusic group(ρl point(IQR O‑2)in the glucOse=・ 008)

Even afteradiustingforvariablespotentiallyinnuencingPIPPchanges(PartiCularlybaselinc PIPP)′ the differences retained statistical signiflcanceThe median tirne to complete the procedure was 2 1nin(IQR2‑4′

min― max rangel‑15)ヽ ″ith nO signiflcant differences between groups.During this stu的 ,there、″ere

no adverse events.

342

Bcrgom at d.

Ｏａ︶﹄餞Ｈ餞 属 ｏ¨
︵
∽︶ ︼
０

muslc

glucOseFigure l.Prematurc lnfant Pain Profile(PIPP)Variation betllveen baseline andafter hcel puncture in 35 newborns treated with three different pain controltreat―ments.Central line=median,box=interquartile range(25 and 75 perccntilc),
whiskers=rangef dots=9utliersi greyhorizontalline=no change(i.e.′ Change=0).
OVerall′ ′Valuc=o.oo8.Post― hoc comparisonsi glucose vs.standard<0.001,music

vs.standard=0.o02,glucose vs.music=0.09.

DISCUSSION
Despitethe recommendations ofthe e対 stingguidelines′ the use ofnonphannacoloゴ ー
caltechniqu9s ofpain relief during procedures such as HL is not uniform (Losacco
et al.′ 2011).The use of automatic incision devices has becn demonstrated to beless traumatic than rnanuallance(Shepherd et al.′ 2006,Vertanen et al.′ 2001).
To ourknowledge′ thisis the rlrstrandonlized controlled trial on the rnanagement
and reduction ofpain using the rnusic of Ⅳlozartin prematurc infants hospitalized
in the NICU.Our results conflrrn that one sirnple nonpharrnacological treatrnent
lirnits pain in neonates during HL procedures′background noiscr and baseline pain′even after taking into account age′with no adverse events and at a low cost

(Table l).variability in thc PIPP change was small and within the range ofclinically
irnportant difference,therefore′ llve conclude、 ve can be confldentin our results.

A Cochrane revie、v(2010)shOWS that sucrosc is saFe and effective fbr reducing
proceduralpain frolnsingle events′ butan optimal dose could notbc identifledbecause&
ofinconsistency in effective sucrose dosage among studics(SteVens,Yamada′
Ohisson′ 2010).In sOme studies,the concentration ofglucose have ranged beh″een
100/O and 30%′ ゃvith an adnlinistered volume bet、 ″een O.05 and 2 ml(3onctto et al.′

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TABLE l.Multivariate Analysis Of Factors Detennining Premature lnfant
Pain Pro■ le(PIPP)VariatiOn After Heel Puncture in 35 Newboms
Difference of

Change of
Variable

PIPP

95%CI

Glucose vs.control‑2.57‑3.60/‑1.53

ρ ValuC<.001

Iusic vs.control‑1.90‑2.9/20.90<.001

PIPP at baseline‑0.70‑1.07/0.34

<001

0.24

‑0.69/1.lo‑0.74‑1.62/0.14

0.04‑0.10/0.19

lノ

lper each point)

A40ι θ
.CI=confldence

６
５

Ga― weckly０１

Hcel left vs.hecl right０
６

Background noise vs.no noisc

interval,Ga=gestational age.

2008,Dilenて 支EIscviers′ 2009,I§ ik′ OZek′ Bilgen′2ooo,卜〔arcatto′ Tavares′

CebeCi′&Silva′ 2011,Stevens′ Yamada′ ct al.′ 2010).ÀLstuも/by Guala ct al.(2001)haS

cvaluated the effect ofdi erent oral glucOsc Or SuCrose solutions(namCしand 50%)on the pain responsc tO HL in nettorns(gestatiOnal age 3841、
concluding that swcet solutions lnay be an easyf useful,safe′

5%′ 33%′veeks)′and cheap analgesic

for rninor invasive procedures in nellvborns(Guala et al.′ 2001).
The usc of glucose′or s、 へ′ectener assOciated 17vith NNS′ often encounters resis―

tance from the parents becausc ofprior beliefs that artiflcial svi/ccteners can dam―
age children′ s teeth in the future(Harrison′parents havealthough theyeasillraCCepted glucOse

2008).In our exPcrience′

sho、 ″n rnore interestin rnusic than in glucOse′

treatrnentiin fact′ these rnvths have becn refuted atleastfor short― terrn glucosc use(CignaccO et al.′ 2007,Golianu′ Krane′ seybold′ AInlgren′ &Anand′ 2007,Harrison′

2008,Harrison′ JohnstOn′ &Loughnan′ 2003).

″
Sonata in D Maior fOr・ L′ o Pianos(K.448)″ has Simple rnelodic elements andrare dissonances that fuel a Pcrccived sirnplicity(Cacciafesta ct al.′2010).The

simple elementsin the music OfMOzart are a result ofthcinauences ofGttmた S(ノ c(Pignatta′ 2012)′ amoVementfrorn、 hich the classical style evolved as a reactionA′

to the comple対 ty oflate baroque music.Mozart′ s mature sり c iS Clearly rooted inand one Ofthe mostrecognizable features ofMozart'sぃた
ork is a scquence ofharmonies Or rnodes that usually leacS tO a cadence in thedorninant or tonal key(BOurdon′ 2010,Carter′ 2008).Some results indicate thatthe neural architecture underlying music processing in ne、 vbOrns is sensitive tochangesin tonalkeyas、 vell as to differencesin consonance and dissonance(Perani
et al.′ 2010).Furthermore′ A/1ozart repeats his rnelodic line fhr rnore frequently than
the tendencies ofthis style′other well― known compOsers(Hughes′ 2001a,2001b′ 2002,Lubetzky ct al.′ 2010),
thiS PCriodicity is the same M′ hich characterizcs brain and bodily function(HugheS′

2001a).A study reported that nurses prefer the presence of recorded rnusic in the
NICU to live musici they believe that it can beneflt preterm infants′
the llvhole staff(Pёlkki′

Korhonen′

Laukkala′ 2012)
̀とparents′andBttF潤344d.
̀ι

Our study had scVeral strengths:(a)It WaS randornized and bloCk balanced′v√ ith a control group:(b)preterrns were randornized cOnseCutively,(c)a range of
diseases/health problems、 vere represented in thC Sample,(d)nO additionaltherapy
and the effect may be solely attributed to the stu(サ treatmenti
for pain was given′

and(C)Well― deincd eligibility criteria.
Some lirnitations need to bc acknowledged.First′ the music allll could nOt be
blinded′ and′ although in these cascs PIPPヽ νas ascertained by tvvo independent
investigators and thcn averaged′

it is possible that individual belicfs on lnusic effl―cacy may have inauenced judgment.Secondlyl cnrolled Children、 ″ere aged>30
Childrenwecks and results could not be extended to younger children.In addition′with no ability to suckle were excluded.Importantt the limited sample size deter―,difference
rnined a lov√ capacity to detcct differences in secondary analyscs(c.g・
betwecn glucosc and music).BeSides,paciners weFe Cqually used during the threc
treatrnents′ and(althOugh it would not qualify as confOunderl,ifSuckling is effec―
tive against pain7it v√ ould rather contribute to reduce differences betWecn groups.
Finallylllve chose not to cOmpare nonpharmaco10gical techniques to the stan―
dard procedure arln in terrns of variation ofindiVidual PIPP parameters because
the variations ofindividual parameters seem to be related to the squcezing oftheheel and to an incorreCt execution ofthe procedure.

CONCLUSIONSThis is the arst randOmized controlled trialin the management ang reduction of
pdin using the rnusic Of A/1ozart in preterln infants hOSpitalized in the NICU,and
conflrrns that the usc of nonpharmaco10gical techniques′ in particular rnusiC andglucose′ for pain control in preterm infantS iS safe and effective.These rneasuresmeet the criteria ofgood clinical practicc and ethiCal needs Ofthe NICU.The resultof this study gives direction for future studies on the topic area,including inves―tigation of sensorv overload and senSOry adaptation in response to COntinuous
terrn)′
exposure to music(ヽ hiCh may reduce itS effect市 enessin the medium long―〜
beliefs
on the effects ofprolonged use ofrepeated doSCs ofglucose′ and on parents′
about glucose use.
rithin― research
Finally great care is nceded in daily practice′ as opposed to v、
areness
prOtOcOls′ to cnforce good practices among health care v,「 orkers′ raise av√
on pain detection and rnanagementin preterrn infants′ and irnprove quality ofcare
for young patients.

lVHAT IS KNOWNT ABouT THIs TOPIC?
The use ofnonpharrnacologicaltechniques forpain controlin preterrn infants iS safe
Sonata K.
and effectiVe′ butFandOrnizedcontrolledtrialsusingthernusicofA/1ozart(″
448′ りas inten/ention forthe rnanagement and reduction ofpain in preterrn inね ntS
hospitalized in a NICU during HL procedure v√ ere not available.

Nοnpた lγ ttrcο :ogical i■ chniqacs ιοRcd,cc Pain

345

WHAT THIS ARTICLE ADDS
The rnusic oflノ lozart(″ SOnata K.448′ ′)is effective in decreasing pain bchavior

ν
′
hen

compared to standard prOcedure.

REFERENCES
Arnerican Academy of Pediatrics cOmrnittec on Fctus and Nellvborn′

Arnerican Academv Of

Pediatrics Section on surgeヮ i canadian Paediatric societyFetus and Newborn Conllnittee′
Batton′ D G.′ Barrington′ K.J.′ヽ
1′ allman,c.(2006).PreVention and rnanagement Of

̀にpain in the neonate:An update Pcσ′
θ″たs,I18(5)′ 2231‑2241.

Ancora′ G。 (2010).The well― bcing ofthe ne■ vも orn infantin neonatalintensive care.んPCσ ゴ
クLAca′ 62(3′ Suppl.1)′ 55‑58.

neⅣa
̀′

Arnon′ s.(2011).ヽ 〔
usic therapy inteⅣ entiOn in the neonatalintensive care unit environment.

JOmα f Dθ PθσFα 五α′87(3)′ 183‑185.

Amon′ S.′ shapsa′ A′ Forman′ L′ Rcge、 R.′ Bauer′ S.′ Litrnanovitz′

I.′&Dolfln′ T(2006).Livemusic is benerlcial to preterm infants in the neOnatalintensive care unit envlronment.

3r誦 ′33(2)′ 131‑136.
Bo′ L.K.′ &Callaghan′

P12000).SOOthingpain― elicited distress in chinese nconates.Rdia饉cs′」θ5(4)′ E49.
Bonetto′ G.′ Salvatico′ E̲′ ミ
ゝrela′ N.′ Cometto′ c′ Gomez′ PR′ &calvo′ B.(2008).PreVenciondel dolor en recicn nacidos de ternlino:Estudio alcatorizado sobre tres lnetodos.IPain
prevention in tellll nconates:Randolnized trial for three rncthods.]ノDε Pθごノσttα ′Iθ 6(5)′ 392‑396.

勺てね油ノοs И⊂gcn″βοsBourdon,A.(2010).力 hσru IttimBσ (ヵ Ъち (調 εθrtЪ 決3ycF"
gSリ イ
θ(HOnors Thesis"九̀Ozθ
in Department of Music university Of Richmond′̀υ
1/A).Retrieved from https://dspace.
lasn/v70rkS Org/bitstream/handle/1o349/915/10mus― bourdonaustin.pdPsequcncc=1
CacciaFesta′ M.′ Ettorre′ E′ Amici′ A.i Cicconetti′ P,Martinelli,v′ Linguanti′ A′ ...Marigliano′ヽ4(2010)Ne、 v frontiers ofcognitive rehabilitation in geriatric age:TheA/11ozart effect(A/1E).
んd勧 ′esげ ∝ rり nわ fο 3′ σnご 3da蘭 ′5f(3)′ e79‑e82.
ε6p■mお 嶋 reC斑銀 gα 5嶋 rperЮi.cpeψmfη grenslcvdalc Press.
θn′ 力
どοp.Ashneld′ New South wales:ヽ ♂
ὺcPrc麟
Cassiむ J.ヽ ヽ
1(2009).ThC effect ofdecibellevelofmusic stimuli and gender On head circum―
ference and phb7siological resPOnSes of premature infants in the NICU.ヵ υロ グ
勿 ,cCaner′ G.(2008).Pimο bο ο
々 Pimο s cο ttρ
pttε ttc anttSS,CΨ r

sゴ

9rル

ThC響 ′イ6(3),180に 190.

c.■ (1999).PrCIude or requicln for the′ AIIozart effect′ ?NQど υ´θ′イθO(6747)′ 826‑827
Cignacco′ E.′ Hamers′ J.P′ Stoffel′ L.′ van Lin.Ccn′ R.A.′ Gessler′ P′ McDougall′&Nene′
Ⅳl.(2007).The efflCacy of non― pharinac010gical interventions in thc management of
Chabris′J.′

procedural pain in preterln and terln neonates.A systematic literature revie、へ′Eυψ caF2

m″ げP血′I19)′ 139‑152.
カυ
Da Silva,c Ⅳ cacao′ J.M.′ silva′ K.C′ Marqucs′ c.F′ &rⅥ ereyl L S.(2013).PhySiO10gicall.′responses of preterm ne、 vbOrn infants subrnitted to classical lnusic therapy.Rθ vislα
Padisiσ σθ Pedia五α′31(1)′ 30‑36
De Battistini′

CSP(洞G.(2011).Rψ CEZiOnc c varfazione働 力1/c ddas″ υ″umzloβ θσθ′ιεπpO θdelle

ZCCmο Ne(TCSi di Dip10ma cOrsO Tricnnale di A/1usicoterapia A̲RI.〕

Professionalc ltaliana A/1usicOterapeuti)lRCPCどノ
I AssoCiazionc

usicalttη θαコσ ttOビonσf

Li9f2 αnご レリガθどοrl′
Italian Association for A/71uSiC Therapy)]Retricved
ionl"ε http://、 〜■♂ヴЪv.atelicrdirnusica.it/docs/musicoterapia/Giorgio° /o20DcO/o20Battistini pdf″εЛ6CS(N/1usic Therapy Thesis′

Bcrgomi ct a.

346
Dilen′B.′

で
更EIseviers′ ヽ4.(2010).Oral glucose sOlution as pain reliefin ncヽ A/borns:Results ofa chnical trial.Bビ r′ 1′ 37(2)′ 98‑105.

Evans′ D.(2002).The effectiveness of rnusic as an intervention for hosPital patients:A sys―

りncedNυ [懇g′ 37(1)′ 8‑18.
tematic revicw.ヵ umθ ′ム NσしFitzgerald′εθf Bυ 〃θttfn′ イア(3)′M.(1991).Deve10pment of pain mechanisms.BIι ish Mcご ゴ

667‑675.
Gibbins′

S,Maddalena,P′ Moulsdale′ W′ Garrard F.′ Jan MOhamed,T.′

NichOls′

A.′

&

ith
Asztalos′ E.(2006).Pain assessmcnt and Pharmaco10gic Fnanagemcnt for infants、 ″25(5)′ 339‑345.

NEC:A retrospective chart audit.Neonaraf NcNOrk′
Giuliani′ A′ Poluzzi′ M.′ Bellisario′

R.′&Bitetti′ S.D.(2005).GI:ψ laid山,pedanzmι οθnttzzα ″″PaZiCn3θ ο

usicO― に響 la suf′

aziOnc σθfご olorθ εごc〃 αnsia[Tttεfttc Scale df vdυ し̀″fuα
fenお αα酸ffZθ σpθ ι
ヴむCお げ ■lusゴ σttcqリ カh6ψ ゴ

たごbypι m mご αttcヶ ″伽 gSCaf].

Bologna,Italy:centro Studi EBN― Dire2ione sen■ zio lnferrnieristico e Tecnico′ Azienda
ospedaliera di Bologna′

Poliこ linico S.Orsola lllalpighi.Retieved from http://wwllv.evldencebasednursing.it/revisioni/1avoriCS/11̲musicoterapia̲dolore.Pdf
Golianu′ B′ Krane,E′ Seybold′ Jり Almgren′ C′ &Anand′ K.J.12007)Nonpharmacological
techniques for pain managementin ncOnates.Semmars h Pttσ ЮI鰹 ′3f(5)′ 318̲322.
Gooding′ L.R (2010).USing rnusic therapy protoCOIS in the treatment of premature infants:
An introduction to current pracuces.Thθ ヵも 加 P電ソ由 οttε ν ′37131′ 211つ 14V
Guala′ A,Pastore′ G′ Liverani′ All.E.′ Giroletti′ G′ Gulino′ E.′ MCnggi,A.L.′ ̲.Garip011′(2001).GluCosc or sucrosc as an analgesic for newborns:A randOrnised controlled blind
trial.ル ″ncttσ Pcdiattca′ 53(4)′271 274.

Harrison′ D.M̲(2008).Oral Sucrose for pain managementin infants:Myths and misconcep―
2イ 2)′ 3946.
Лθ
tt NWSI昭 ′■ons.ヵ um〆 げ比οHarrison′D.′ JohnStOn′

L.′&Loughnan′ P (2003).Oral Sucrose for procedural pain in sickmご げPacご fσ 面
hospitalized infants:A randomized― cOntrolled trialヵ υ

fめ ′
ωσ〈
勤盟 Hθ α39(8)′ 591‑597.

Hartling′

L.′

Shaik′ M.S.′ TiOSVOld′ L′ LCiCht′

R.′

Liang′ Y′ &Kumar′M.(2009).Music for

medicalindications in the neonatal period:A systematic revlew ofrandornised controned
οn′ laf]ダfこon,9イ (5)′ F349‑F354.
trials̲鮭ふ んes(ゾ DiSα 7Sc h Cわ nふοοtt Fθ taf anσ rゞθHodges,A.L.(2010).Preterm infants′ responses to music:An integrative literature revic、へ√.

Iθ (3),1‑16.
Souttcmの 加θヵum〆 げNυ rsitt RcsCα 油′
2
396‑417.
″iα′
&3由
fFリ
.The
Mozarteffect″Hughes′ J.R(2001の
ッ
′
I
Sο
Cfθ
α
酌
CRの
ケ 9rMe磁血 θ,9ィ (6)′ 316.
Hughes′ JR:(2001b).ThC Mozart effectヵ υmα 9「Hughes′ JR.200助 .The Mozart effect AddidOnal data.″ ifリ ツ &B由 昴イοri 3(動 ′182‑184)′

1§ ik′

U・ ′OZck′

E.′

Bilgen′ H.′ &Cebeci′ D.(2000).COmparison of oral glucose and sucrosc
aninf OrC・ irfヵcヵ umαεノ勧 αづШηごげ山θ

げ陶

solutions onpain responscin nconates.動Pamsο ごc夕 ′I(4)r275=278.
JOhnStOn′ c.C.′ Fernandes′ A N/1.′ &L Campbell― Yeo′ L4.(2011).Pain in neonates is different.
Pain′ f52(3′Suppl.),S65‑S73.

Kemper′ K.J.′ &Danhaucr′ S.C.(2005)MusiC as therapッ LSο u山 ル
LagO′ P′ Garetti′ E′ Merazzi′ D.′ PiCragostini′L.′

Ancora′Ottη 〆′
98(3)′ 282=288.

̀cttcalメ. .Bellieni,C.ヽ「αPσ εdianca′ 98(6),932‑939

G.′ Pirelli′ A.′(2009).Guidelines for procedural pain in the newborn.ス ̀ξ
M.′ Greisen,G′ Haumont′ D′ Pallas― Alonso′ C.R.′ Pierrat,V′ ̲… SiZun′

Losacco′ ヽ4,Cuttini′

J(2011).HCel blood sampling in Europcan neonatal intensive care units:Compliance
ごNemα d輛 th pain management guidelines.ん でわIVesげ Disc Ch aガ 曲 οοご 比 d
Eご f″ On′ 96(1)′F65‑F68

Lubetzky R′ Mimouni′ FB.′ Dollberg′ S.′ Rcifen′ R′ Ashbel′ G.′ &Mandel′ D(2010).Effectofmusic by Mozart on energy expenditure in gro、 ving prcterln infants.Pcdia饉 cs′ 125(1)′c24‑e28

Nο 71pha鶴:Ogical■ ch■ jqtts tο R̀dacc Paれο

34/‐

LIarcatto′ J.D.0′ Tavares′ E C.′ &silva′ YPE.12011).Bencicios e lirnitacё
es da utilizacao

da glicose no tratamentO da dor ern ncOnatos:RevisaO da literatura.IBCneflts and lillni―
tations ofthe usc of glucose fOr the treatlnent ofPain in nconates:A literature reviev71.
Rε ルis″ 3mダ ′奮 aDettα,alntCns市α′23(2)′ 228‑237̲

L4cLachlan′ J.c.(1993).A/1uSiC and spatialtask PcrfOrmance NaluFθ

′366(6455)′ 520.

Morrovら c.′ Hidinger′ A.′ &WilkinsOn― Faulk′ D.(2010).Reducing neonatal pain during routinc
heellance procedures.九 ィ
cPo「 コ
晩cヵ η頭cmヵ υ
mダ げMarcmご dh」 σNυ ぉfη 3 35(6),346354
Nantais′ K.M.′ &Schellenberg′ E.G̲(1999)ThC MOZart effect:An artifact of preferenceChο]は a」 3面 CC′ ′O14)′ 370■ 73.
も ′Newman′J.′

Rosenbach′ J.H.′ Burns′ K.L′ Latimer′ Bc′ Matocha′ H.R̲′ &Vogt′ ER.(1995)

An cxperimental test Of″ the A/10zart effect″ :Docs listening to his llnusic improve spatial
ability?ざαQq9̀ゥ α θησ MObrSし ′
む,8′

(3′

Pt.2)′

1379‑1387.

Okan′ R′ cOban′ A.′ Ince′ z.′ Yapici′ z′ &can′ G.(2007).Analgesia in preterin newborns:

The comparative effects ofsucrosc and gucosc.Eυ
″ρC
1017‑1024.

m″ げた砒rttCS′ f
力υ

Olson′ s.L.(1998).BedSide rnusical care:Applications in pregnanc377 childbirth′

Care力 um″ げ 0誌 た厨 cの aCCο 」
9ゴc"σ N(lo′

and neonatal′27(0,569‑575.
Ornetto′ L〔 。(2010).Prelicvo di sangue da sitO periferico:Puntura del dito o del ta1lone enα 日 ヽ
Ⅸ鍵

venipuntura.In P Badon&A.Zampieron(Eds)′ PrOCedurcゴ rmゴ θ法 がchc tt Pcご fσ ttα崚σ″εЛLIttlngpЮ
lPCご ′

ごurel.(pp.398‑403).Milano′ Italy:casa Editrice Ambrosiana.

Perani′ D.′ Saccuman,M.c.′ Scifo,P′ spada′ D′ Andreolli′ G.′ Rovelli′ R.′ .…

Koelsch′ s.12010).

Functionalspecializations formusicprocessingin the human nen7born brain.Proccedings
9rttθ Nσ ti9n″ 43ade町 げ SCienccsげ 酌Cυねゴ
ι
θσS″ ι 9「 ん12顔Ca′ fθ /(10)′ 4758■1763.

Pignatta′ P12012).砺 むι
わ臨 Zart′θttψ ゴ
σσC′ d01orer″ ス.Mοzσ rぁ smattρ αごυepianο ―ゴ0ゴ θι
たα 60fわ αευ″冴PInο pttα ιιυrθ dcllaルnね五
one d6sα Л
ご″のαε"いむ6ψrραinm αrmmι 6SοЛσttκ イイ8げ N崚 銀 gノ勧 α虎 婚 Mozα⇒=
ぎ Qaο 励 lP%ο Zart切
29ρ afS力 rお FCnゴ ηgン Pttο 乳 口aFla ごガ 鰯σ″ 3razloι 血 ゎ 閉 ル ゴOβ ].Retneved

イのr、
韓 tJ6′ イ

fromhttpノ /■ ぃ Ⅳ√
.fondazionegraziOttin.org/Pdf/articoli.php?ART TYPE=STRATEGIE&N̲
〜FATHER=15726

Pё lkki′ ■′Korhonen′ A.′ で支Laukkala′ H.12012).Nurses′ expectations ofusing lnusic for pre―maturc inね ntsin neonatalintensive care unit.ヵ

um″ げ Pediattc」 馳βttg′ 2/(4)fe29‑c37

Rauscher′ RH.′ shavら G.L.′ &Ky K.N.(1993).MusiC and spatial task Pcribllllance.Naι urθ
365(6447)′ 611.

′

Rocchi′ A.(2007).ノ ヽfυ 」

C Prfmα fo麟 nzia,υ n Pcrcο rSο ροSSibrc(Dip10ma di Laurea iǹσヽlusicologia′ Fondazione
lstituto Aliusicalc dellaミゝ1le d′ Aosta′ IT)[A/1usic and young

children:a possible path.(Dissertation in A/1usicologッ しヽ4usic lnstitutc of Valle d′ Aosta)].
Rctricved fronl https://‑7v.libreriauniversitana.it/tesi/oooAR01188578/autore― alessio―
rocchi/musica― c― prilna― infanzia― un―possibile.htrn
Santullo′

A.(2009).LC SCale″

PcrcorSO―

vafυ ヒz10nθ tt sa″ 麟 sanita lRσ ょ加g Sε αItaly:McGraw― Hill.
Shepherd′ AJ′ Glenesk′ A.′ Niven′ c.A′ &L〔 ackenzie′

力 力εダ由]MilanO′

J.(2006)A Scottish study ofhccl― prickblood sampling in newbottn babiesん 4た れクたζ
22(2),158‑168.
′
ソぅ
Spencc′ K.′ Henderson― smart′ D.′ Nevら K.′ Evans,c.′ v√ hitelavら
J.メ 更W001nough′ R.12010)
Evidenced― based clinical practice guideline for rnanagement of nellvborn pain.メ
9β R7edial″οamα fαnd ch〃 σttθ α肋′
イ6(4)′ 184‑192

Standley7J.M.(2002).A meta― anaり siS Ofthe efflcacy ofmusic therapy for premature infants.
力 LIImグ げ P鎌αttc Nisi電,1/12),107‑H3‑―

Standlり J.M(2011′ November).2θ た

げ muSfε ttcttη ソヱ 餡 油 加 山εNICtt Af7叩Й

mc″ ―θn■しsiS.POStersessiOn presented atAnnual conferencc ofAmerican Music Therapy
Association,Atlanta′ GA.

348

:.
BCrgXni ct α

Steele′ KA/1′ dalla Bella′ s.′ Peretz′ I.′ Dunlop′ T′ Dawe′ LA′ Humphrey

G K′ .01rnstcad′

C.G (1999).Prelude or requien■ for the′ ヽlozart effect′ ?Nαιurθ ′イOo(6747)′ 827‑828.
Stevens′ B.′ JohnStOn′

C.′

Petryshen′P′&Taddio′ A (1996).Premature infant pain proflle:fヵ υm″ げ Pam′ ゴ
2(1)′ 1322

Development and initial validation.cI′ ″Stevens′ B′ JohnstOn′ c.′ Taddio′ A.′ Gibbins,S.′&YamadaJ.(2010).The premature infant

painpronle:Evaluation 13ycars a■ er development.ainた 〆ヵ umα Pク in′ 26(9)′ 813‑830
げStevens′ B.′ Yamada′ J.′ gt OhISson′ A (2010).sucrose for analgeSia in newborn infants under―

goingPainful procedures.∽ め″ncρ αttb

ttRaノ イo帽
0(1)′ CD001069.
9び■ehub′ sE.(2001).Musical predisposiuons in infancy.AlnafsげcNewyOrk Acadc町 げ̀oniわ'SacmαScienccs′ 930′ 1‑16.

Valenl′ vE.′ de Abreu′ L.C.′ Guida′ H.L.′ Vanderlei′ L.C′ Lima Ferreira′L.′&Ferreira′ c.

(2012).MusiCalauditorystimulationandcardiacautonttmicregulatiOn lnM saad&R.deMedeiros(Eds)′ COmpFem ″ダ め3rapicsルrttC σοntcmpDI町 力calttCaFe′ Rctrieved from
httpノ /vハ Ⅳ
wv.intechopen.com/b。 。ks/complementary therapiё s̲fOr― the― con"mporary―
healthcare/mlsiCaliauditOry stimulation― and― cardiac― autonOmiこ ―rcgulation
Vani′s.N.12011).ASS

釦

ι ごm

甲

ιげραfn加 山εЛ帥 うο
m.NNF Clinical Practice

Guidelines.尽 etrieVCO frOm httpノ /nnfpublictttion・ Org/uploads/Anicles/fc76cdbc― b5f8‑

40f5,8285‑52467916fec41pdf
Vertanen′ H.′ Fellman,V′ BrOmmels,M′ &viinikka′ L.(2001)I An autOmatic incisiOn devicefor obtaining b100d sa■ plesiom thc hcels ofpreterminfants causё sless damage than aconventional manuallancett Aに わNso/DisCasc■ Gほ Jttο οd Felaf and NeOnα laf Eご Fぼοn,
8イ (1),F53‑F55.

・ThC authOrs wish to thank the parenも Ⅲd neё nateswhO particゎ ated m
4よ nο ttC砲 塑 お
this study Thank allthe nuFSing and rnedical staffofthe NICv and Neonatal Patho10gy who

cooperated in this stu的 .A special thanks goes to the director ofthe Structure of Nё onatal
hiS profession● li5m and exper,isc encOurages thc opera―
tors to aCt responsibly and continuously improve care.

Path010S and NICU evory dayWitいCorrespondence regarding this article should be directed tO Piera Bcrgonli′ RN′ IRCCS
Fondazione Policlinico san Matte。 ′Piazzale volontari del sanguc,3 27100 Pavia′ Italia.
E― lrnaili

p.bergomi@̀matteo:pv.it