Effect of Yakson touch on behavioural response among late preterm neonates admitted in neonatal intensive care unit

INTRODUCTION

The rate of preterm neonates care in NICU has increased due to advancement in medical technology.¹ Prematurity is a major risk factor for cognitive delays, behavioural disorders and neurological development disorders.² Primary needs of neonates are manifested through different behaviours and responses.³ Behavioural patterns in neonates mainly consists of sleeping, waking and activities such as crying.⁴ Sleep and waking are associated with developmental outcomes since they reflect the immediate response of the neonate to the stimulation caused by central nervous system function.^5-9 To evaluate the possibility of different diseases medical experts focus on the behavioural changes of neonates.^10-12 Since preterm neonates experience numerous stressors in the NICU environment, identifying interventions that have immediate soothing effect is essential.¹³ Chronic exposure to stressors may suppress hypothalamic pituitary-adrenocortical activity and result in a decrease in the neonate’s ability to cope with acute stressors associated with illness or medical interventions.¹⁴ The level of alertness of preterm neonates could be controlled through touching. By inducing a relaxed state, the behavioural organization of preterm neonates will be improved.¹⁵ It is also reported that an increase in sleep due to tactile stimulation is related to relaxation.¹⁶ Touch, the most popular sensory stimulation for neonates is considered absolutely essential for the developing neonate.¹⁷ sensory stimulation could enhance physical development in premature neonates.¹⁸ By reducing stress, kinesthetic stimulation increases developmental growth in these neonates.^19-21 Yakson is one of the traditional Korean therapeutic touches given to children to reduce their pain or decrease their stress levels.

It is a traditional belief that it was first used among Koreans to relieve their sick children’s pain or discomfort by gently caressing them on the aching body part. This act of caressing is named "Yakson," where "Yak" means medicine and "son" refers to hand. The Yakson protocol is effective in preterm babies as it includes touching the baby gently and slowly with pre-warmed hands without any pressure.²² So far only few studies have been conducted on effect of Yakson touch and that too comparison between the effect of Yakson touch and gentle human touch was done. Only scanty studies have compared the Yakson effect with control group and that too with small sample size. Only in this study large sample size was utilized and randomized controlled trial was carried out and among sampling population only late preterm neonates were enrolled. In previous study only ABSS score was assessed but in this study in addition to ABSS score different categories of ABSS status and correlation of ABSS score with clinical characteristics of preterm neonates were also assessed.

METHODS

A randomized controlled trial was adopted to assess the effect of yakson touch on behavioral response of late preterm admitted in NICU. The study was conducted in NICU of Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) hospital during August 2022 to February 2023. The sample size was estimated by using the method of superiority trial for the quantitative outcome with a minimum expected difference in the mean score in ABSS between the groups as 5 with an SD of 8 at a 5% level of significance and 80% power, 84 preterm neonates were enrolled in the study.

Neonates with gestational age between 34-37 weeks, admitted in NICU and not treated by sedatives and receiving feeding every 2 hours were included in the study. Preterm neonates those who were on kangaroo mother care or on phototherapy or with major congenital anomalies or underwent any surgical procedures or on ventilator were excluded from the study. Everyday preterm neonates who met the inclusion criteria were selected through consecutive sampling method. Informed consent was obtained from parents. Data regarding clinical characteristics of preterm neonates were collected from medical record. Neonates were randomized to experimental and control group by block randomization with varying block sizes generated through the computer. Allocation concealment was done using sealed opaque and serially numbered envelops (SNOSE) method. In experimental group baseline behavioural responses were assessed on the first day and along with routine care yakson touch was provided.

Yakson touch was given for 15 minutes once in a day (morning) for 6 consecutive days after breastfeeding to the neonates. The procedure had 3 components-hand resting (5 minutes), gentle caressing (5 minutes) and hand resting (5 minutes). The procedure was as follows:

With warmed hands hand resting was given for 5 minutes-resting one hand on the chest and abdomen of preterm neonate, while supporting the back with the other hand. Next 5 minutes gentle caressing in the same hand position stroking gently the chest and abdomen clockwise in a circular motion. Next 5 minutes hand resting. On 3rd day and 6th day, 5 minutes after the intervention the behavioral responses of neonates were assessed.

In control group, neonates received routine care for 6 days, which included essential newborn care (skin care, eye care, cord care and changing diaper), exclusive breastfeeding through paladai or direct breastfeed, prevention of hypothermia by using radiant warmer and prevention of sepsis by following strict aseptic techniques. On the 3rd day and 6th day, the behavioral responses of the neonates were assessed.

Data collection instruments had two section, first section included data regarding clinical characteristics of late preterm neonates. It comprised of clinical characteristics of the baby such as date of enrollment, day of life at enrollment, hospital no, gender, gestational age, birth weight, date of admission, APGAR score.

Second section had data on behavioural responses of the late preterm neonates was evaluated by using the Anderson Behavioral State Scale (ABSS). It comprised of infant’s behavioral states including 1; regular quiet sleep, 2; irregular quiet sleep, 3; active sleep, 4; very active sleep, 5; drowsy, 6; alert inactivity, 7; quite awake, 8; active awake, 9; very active awake, 10; fussing, 11; crying and 12; hard crying with interpretation of 1-5 indicate infant sleeping, 6-8 indicate–awake or calm and 9-12 indicate–restless activity or fussiness.

The study was approved by the Nursing Research Monitoring Committee (Regn No: JIP/CON/NRMC/M. Sc/2021/PN/5), JIPMER and Institutional Ethics Committee for Human Studies (Regn No: JIP/CON/IEC/M.Sc./2021/PN/5), JIPMER.

The trial was filed with the clinical trial registry of India and the registration number is CTRI/2022/09/045310. Data were analyzed using SPSS version 19. Both descriptive and inferential statistics were used for analysis of data. Descriptive statistics (Frequency, percentage, Median, mean, standard deviation) were used to describe the clinical and demographic variables of study participants.

Chi-square test and student independent test was used to compare the behavioral status at different point of time. And spearman correlation was used to identify the association of behavioral response with clinical variables.

RESULTS

Among 84 late preterm neonates’ majority were males and most of them had low birth weight (Table 1). median Gestational age was 35 weeks. Birth weight and APGAR score was comparable between the groups (Table 2). Comparison of ABSS status between the groups at baseline is not significant. On third and sixth day after the intervention significant changes were noted (Table 3).

The baseline ABSS score among the participants in the experimental group decreased after 3 days of intervention and also after 6 days of intervention and it was significant (Table 4). Comparison of change in ABSS score on average over time between groups showed significant difference on third and sixth day on after the intervention and it was significant (Table 5). The correlation between difference in ABSS score and clinical variables in the intervention group showed significant negative correlation with APGAR and in control group birth weight showed significant negative correlation (Table 6 and 7).

*Chi square.

*Independent student t- test.

*Chi square.

*ANOVA.

*R M ANOVA.

^a Spearman correlation, ^bIndependent student t-test, *significant.

^a Spearman correlation, ^bIndependent student t-test, *significant.

DISCUSSION

This randomized controlled trial included 84 newborns. Comparison of change in mean scores of ABSS over time between groups showed that change was significantly higher in the experimental group than in the control group. In consistent with this a quasi-experimental study conducted by Eshghi et al, in Afzalipour hospital at Kerman, Iran, among 60 premature infants showed that the mean score of the ABSS in experimental and control group were 4.83 (0.14) and 10.63 (0.14) respectively and it was significant (p=0.001).²³ Similarly a quasi-experimental study conducted by Bijari et al, in a hospital under the Kerman University of medical science, in the south-east of Iran, among 90 preterm infants reported that the Mean (Standard error) of the ABSS score for the Yakson group, gentle human touch (GHT) group and control group were 4.83 (0.14), 4.85 (0.14) and 10.63 (0.14) respectively and it was significant (p=0.000).²⁴ Furthermore IM et al, in South Korea conducted a study among 40 preterm infants in NICU of 2 general hospitals and revealed that comparing Yakson touch group and gentle human touch group the mean change in ABSS was from 0.50±1.56 to -1.31±1.21 in Yakson group and - 0.11+-0.59 to-0.71±0.67 in gentle human touch group and it was significant p<0.01.25. In this study in experimental group baseline ABSS score decreased on third day and on sixth day. Similarly, a study by Eshghi et al, reported that in Yakson group baseline ABSS score was 8.96±0.263 and on third day it decreased to 5.57±0.176 and on fifth day further decreased to 5.14±0.109.23In consistent with this a study by Bijari showed that the baseline ABSS scores were 9.51±2.09 and on third day it was 3.26±1.62 and on fifth day it was 2.38±1.08.²⁴

In current study the sleep state of the late preterm neonates were enhanced in the experimental group when compared to the control group on 3rd day and 6th day. Similarly a comparative study performed by Im et al, in general hospitals in South Korea, among 40 preterm neonates showed an increased percentage of sleep states from 74% to 90% in yakson group compared to 68% to 75% in gentle human touch group.²⁵ In consistent with this a quasi-experimental study conducted by Im et al, in South Korea, to assess the effect of Yakson and Gentle human touch (GHT) on preterm infants’ stress and behaviors compared to routine nursing care among fifty-nine preterm infants showed an increased percentage of sleep states from 75% to 90% in yakson touch group compared to 68% to 77% in human touch group.²⁶

In current study the state of awake was reduced in yakson group. Similarly, a study by IM et al, reported that waking state of neonates in yakson group was reduced from 19% to 9% whereas in gentle human touch group it was 26% to 21%.²⁵ In consistent with this IM et al in 2008 showed that in yakson group waking state reduced from 19% to 9% whereas in gentle human touch group it was 28 % to 21%.²⁶ In current study the state of fussiness was reduced from 59.5% to 0%. In consistent with this a study by IM et al, in 2009 revealed that the fussy state of infants was reduced from 7% to 1% in Yakson group compared to 6% to 4% in gentle human touch group.²⁶ Similarly a study by IM et al, in 2008 reported that in Yakson group the fussy state reduced from 8% to 0% whereas in gentle human touch group it was from 7% to 6%.²⁵

In current study there was a significant negative correlation between APGAR and the behavioral response of the neonates in the intervention group. Contrary to this, a study by Bijari BB et al, revealed that the APGAR and behavioral response of the neonates had no correlation (p value=0.15).²⁴ In this study there was a significant negative correlation between birth weight and the behavioral response of the neonates in the control group. Contrary to this, a study by Bijari BB et al, revealed that the birth weight and behavioral response of the neonates had no significant correlation (p value=0.35).²⁴

There was no association between gender and behavioral response of the neonates in the intervention group. Similarly, a study conducted by Eshghi et al, revealed that there was no correlation between premature infants' gender and the ABSS score of neonates.²³ In consistent with this a study by Bijari et al, also revealed that there was no significant correlation between premature infants’ gender and the ABSS score of neonates (p=0.15).²⁴ Generalization of the study would be limited as this is a single-center study. More over only late preterm neonates were enrolled in the study.

CONCLUSION

Yakson touch is a gentle touching procedure that provides minimal and safe stimulus suitable for preterm neonates. Yakson touch showed significant improvement in behavioral state of the late preterm neonates. Moreover it is an inexpensive approach which can be added in the NICU protocol. This study adds one more piece of evidence to reduce the stress and improve the behavioral states among preterm neonates.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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