Intensive & Critical Care Nursing xxx (xxxx) xxx

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Intensive & Critical Care Nursing

journal homepage: www.elsevier.com/iccn

Research article

The effect of maternal voice for procedural pain in pediatric intensive

care unit: A randomised controlled trial
Çiğdem Erdoğan a,⇑, Türkan Turan a, Bakiye Pınar b
a
Faculty of Health Science, Pediatric Nursing Department, Pamukkale University, Denizli, Turkey
b
Pamukkale University Hospital, Pediatric Intensive Care Unit, Pamukkale University, Denizli, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The aim of this study was to evaluate the effectiveness of the maternal voice in reducing pain
Received 25 June 2019 during painful procedures in children between one and three years old receiving treatment in paediatric
Revised 24 September 2019 intensive care unit.
Accepted 28 October 2019
Design and methods: This research was designed as a randomised controlled experimental study. Sixty
Available online xxxx
children were randomised into two groups, the maternal-voice group and the controls. The children in
the maternal-voice group listened to the maternal voice during the procedure. Although questionnaire
Keywords:
forms were used to determine the descriptive characteristics of infants, the Face, Legs, Activity, Cry,
Paediatric intensive care unit
Nurses
Consolability (FLACC) pain assessment scale was used to evaluate pain level. Heart rate and oxygen sat-
Pain management uration were also measured.
Maternal voice Results: There were significant differences in the pain, heart rate and oxygen saturation levels between
the maternal-voice and control groups. Pain levels and heart rates of the children in the experimental
group during and after the painful procedures were much lower, and their oxygen saturations were
higher than those of the children in the control group.
Practic implications: Distraction methods, such as listening to the maternal voice, should be used as a
nursing intervention to reduce pain and decrease heart rate and increaseoxygen saturation in children
during painful procedures in the paediatric intensive care unit. The maternal voice is recommended as
a helpful option in cases when a pain control method is required. Future research needs to explore dif-
ferent interventional practices.
Ó 2019 Elsevier Ltd. All rights reserved.

Implications for Clinical Practice

 Nurses should be aware of pain during procedures and use a method for pain relief accordingly.
 The maternal voice is extremely effective in preventing children’s pain.
 The maternal voice should be used as a nursing intervention to reduce pain during painful procedures performed on children in the
PICU.

Introduction and children show behavioural and physiological responses during

Children experience fear and anxiety due to frightening experi-
ences caused by painful procedures. Children in paediatric inten-
sive care units (PICUs) are exposed to a large number of
procedures that cause pain, and studies have reported that infants
⇑ Corresponding author.
E-mail addresses: cigdemg@pau.edu.tr (Ç. Erdoğan), turkanturan@pau.edu.tr
(T. Turan).
such procedures. It is therefore quite important and difficult to
evaluate and manage pain in children, which is why pain is consid-
ered the fifth vital sign in many hospitals (Gibbins et al., 2008;
Turner 2005; Stinson et al., 2008; Uman et al., 2008; American
Academy of Pediatrics, 2001).
Infants and children showed the same response when they
were exposed again to a procedure they had experienced before
a painful procedure (e.g., wiping with alcoholic cotton) (Taddio
et al., 2002).

https://doi.org/10.1016/j.iccn.2019.102767
0964-3397/Ó 2019 Elsevier Ltd. All rights reserved.

Please cite this article as: Ç. Erdoğan, T. Turan and B. Pınar, The effect of maternal voice for procedural pain in pediatric intensive care unit: A randomised
controlled trial, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2019.102767
2 Ç. Erdoğan et al. / Intensive & Critical Care Nursing xxx (xxxx) xxx
There is a significant relationship between the behaviours of par-
ents and the behaviours of children during medical procedures. Par-
ents reported that children were worried during painful procedures
and that they wanted to reassure their children. Parents made
confidence-instilling speeches and apologised when their children
were upset during the procedure. It has been shown that nurses’ or
parents’ speeches are helpful in relieving children’s pain and discom-
fort (Chambers, et al., 1997; Franck et al., 2005; Cohen et al., 2000).
Studies in neonatal units have reported improvement in physi-
ological indicators (heart rate, respiratory rate, oxygen saturation,
pain level, etc.) of infants who heard their mothers’ voices during
painful procedures (Azarmnejad et al., 2015; Doheny et al. 2012;
Rand and Lahav2014; Arnon et al., 2014). Although numerous
studies have examined the effectiveness of the mother’s voice in
neonatal intensive care units (Azarmnejad et al., 2015; Doheny
et al. 2012; Rand and Lahav2014; Arnon et al., 2014), only a limited
number of studies have been conducted in paediatric intensive
care units (PICU) (Cignacco et al., 2007).
This study was designed as a randomised controlled trial to
determine the effect of the maternal voice on painful procedures-
performed on children.
Methods
Design
Structured as a randomised-controlled prospective study, the
objective of this study was to determine the efficacy of the mater-
nal voice during painful procedures in children one to three years
of age hospitalised in PICUs. The efficacy of the mother’s voice was
assessed by pain intensity, heart rate and oxygen saturation.
Setting
Data was collected from a paediatric ICU in a hospital in the
Aegean region of Turkey. The unit where the study was completed
had 10 beds, one of which is in an isolation room. An average of
500 patients were admitted during a year. The children were
admitted to the paediatric ICUs mainly due to respiratory disor-
ders, need for mechanical ventilation or dialysis or life-
threatening illnesses. The unit patient population had a wide range
of diagnoses, ranging from cerebral palsy to suicide, ketoacidosis
and acute and chronic renal failure. In recent years, due to the
increasing number of migrants coming into the country, a wide
range of ethnic children were admitted. A total of 14 nurses
worked in the unit. The family visiting hours of the clinic where
the study was conducted were limited to 15 minutes per day for
each parent. Parents received information and visited their child
for only 15 minutes. Other family members (grandparents, sib-
lings, etc.) are not allowed to visit. There was no place where par-
ents could stay in a hospital. Families coming from outside of the
city had either to return to their homes or arrange accommodation.
Sample
The study population consisted of children one to three years old,
hospitalised and treated in a paediatric intensive care unit. The inclu-
sion criteria stipulated that the child was between one and three
years old; had not been intubated; was not taking analgesic, sedative,
or muscle relaxant medications; and parents spoke Turkish or English
and agreed to participate in the study. We calculated that a sample
size of 60 infants would achieve 80% power and a = 0.05 to de-tect
a difference of 0.1 points in standard deviation using the G*Power
3.1.3 program (Canbulat et al., 2014; Inal and Kelleci, 2012; Sahiner
and Bal, 2016). The study data was collected between October
Please cite this article as: Ç. Erdoğan, T. Turan and B. Pınar, The effect of maternal voice for procedural pain in pediatric intensive care unit: A randomised
controlled trial, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2019.102767
2018 and April 2019. The total number of children matching the
inclusion criteria was 75 between these dates. The total of the study
population consisted of 60 children. Children of parents who did not
agree to participate in the study and therefore could not hear their
mothers’ voices during procedures were excluded. The 60 participat-
ing children were randomly assigned to the experimental and control
groups by the urn randomisation method (Fig. 1).
The urn randomisation method was used as an equivalent to the
full-randomisation method. This method included two parameters.
These parameters were selected as balls of two colours, red and
white. In this study, the white coloured ball was determined as
the control group and the red-coloured ball as the experimental
group. When a child matching the sampling criteria was found,
these balls were placed in a black-coloured pouch pre-prepared
by the researcher and one of the researchers asked the child or
mother to close his or her eyes and choose one of the balls inside
the pouch. The mother or child who chose the ball did not know
which colour represented which group. At the same time, a second
researcher followed the selection process. The child was assigned
to the experimental group or the control group by the colour of
the ball chosen. Thus, it was ensured that the children were ran-
domly distributed to the two groups (Wei and Lachin, 1988).
Instruments and measurements
Descriptive characteristics. A questionnaire was developed by the
researchers in accordance with the information available in the liter-
ature. The form asks for information about the child’s age, gender,
medical diagnosis, heart rate, oxygen saturation and so on.
FLACC pain scale. Measurements were performed through evalu-
ation of the five behavioural parameters in the Face, Legs, Activity,
Cry, Consolability (FLACC) scale developedby Merkel, Voepel-Lewis,
Shayevitz and Malviya in 1997. A score of zero indicated that the
infant did not feel pain; the score between 1 and 3 showed mild pain;
a score between 4 and 6 showed a medium level of pain and a score
between 7 and 10 showed severe pain (Merkel et al.,1997).
Intervention
The children of the parents who agreed to participate in the
study were allocated to the experimental group or the control
group by the urn randomisation method. Then, a second interview
was conducted with the parents, and their written and verbal con-
sent was obtained. In the second interview, the mothers of the chil-
dren in the experimental group were given a voice recorder and
explained that they could tell a story, sing a song or talk to their
children by recording the same into the voice recorder, which their
children would listen to during painful procedures. It was clearly
explained to the parents that the goal with this practice was to dis-
tract the children from the process. The child would listen with the
help of a headset to cover five minutes before and after the proce-
dure to be applied. Painful procedures were usually performed
during vascular access, blood collection or aspiration.
Data collection
The parents of the children who matched the inclusion criteria
were informed about the study 24 hour after their admission to the
paediatric intensive care unit by a nurse who was involved in the
study group and worked in the unit. The questions the parents
asked were answered, and the decision to participate in the study
was left to the discretions of the parents. Pain level, heart rate and
oxygen saturation were evaluated before, during and after the pro-
cedure. Pain level was measured by FLACC by the nurse researcher.
Pre-procedure measurement was performed to evaluate the differ-
ence between the groups.
 Ç. Erdoğan et al. / Intensive & Critical Care Nursing xxx (xxxx) xxx 3

Fig. 1. CONSORT flow diagram of randomized controlled trial.

Ethical considerations Results

Approval for the study was obtained from the Ethics Committee Descriptive characteristics of the children in the mother sound
of PamukkaleUniversity Faculty of Medicine (60116787- and control groups were evaluated. No statistically significant dif-
020/58588). ference was found between groups (gender, age, and diagnosis;
p > .05). There was no statistical difference between the groups
for average pain scare, SpO2 and HR before procedurs (p > .05)
Data analysis (Table 1).

Statistical analyses for this study were completed using SPSS 21.
Baseline characteristics among the groups data were analyzed
using the Chi-square test and Student’st-test. A comparison was
made between the parametric data, ie, heart rate, oxygen satura-
tion and pain levels of children, using a Student t test.
Comparison of pain levels between the groups
Pain levels were evaluated twice, during and after the proce-
dure. During the procedure, there were significant differences in
the pain levels between the experimental and control groups

Please cite this article as: Ç. Erdoğan, T. Turan and B. Pınar, The effect of maternal voice for procedural pain in pediatric intensive care unit: A randomised
controlled trial, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2019.102767
4 Ç. Erdoğan et al. / Intensive & Critical Care Nursing xxx (xxxx) xxx

Table 1
Baseline characteristics of the study groups.

Mother’s-voice group (n:30) Control group (n:30) v2 p

Gender
Female 11 13 0.213 .451
Male 19 17
t p
Age 2.0 ± 0.82 2.0 ± 0.21 1.471 .082
Pain scores 1 ± 0.65 1 ± 0.21 1.321 .462
Heart rate 124 ± 10.9 123 ± 11.2 1.254 .384
SpO2 levels 97 ± 1.62 97 ± 0.42 1.487 .215

Notes: Data is represented as number (percentage) or mean ± standard deviation where appropriate.

Table 2
Comparison of procedural pain scores, heart rate and SpO2 levels of the study groups.

Mother’s-voice group (n:30) Control group (n:30) t p

Pain Scores 4.76 ± 2.43 7.66 ± 3.75 3.041 .000
Heart Rate 134.36 ± 16.07 167.66 ± 10.94 3.123 .000
SpO2 levels 95 ± 0.25 93 ± 1.12 3.240 .000

Note:Data is represented as mean ± standard deviation.

Table 3
Comparison of pain scores, heart rate andSpO2 levels of the study groups after procedure.

Mother voice group (n:30) Control group (n:30) t p

Pain Scores 2.26 ± 1.44 3.16 ± 1.37 3.311 .000
Heart Rate 119.73 ± 10.77 131.66 ± 9.64 3.415 .000
SpO2 Levels 97 ± 1.01 96 ± 0.21 2.542 .041

Note. Data are represented as mean ± standard deviation.

(p = .000); the experimental group (4.76 ± 2.43) had significantly
lower pain levels than did the controls (7.66 ± 3.75) (Table 2). After
the procedure, there were significant differences in the pain levels
between the experimental and control groups (p = .000); the
experimental group (2.26 ± 1.44) had significantly lower pain
levels than did the controls (3.16 ± 1.37) (Table 3).
Comparison of heart rate levels between the groups
Heart rate levels were evaluated twice, during and after the pro-
cedure. During the procedure, there were significant differences in
the heart rate levels between the experimental and control groups
(p = .000); the experimental group (134.36 ± 16.07) had signifi-
cantly lower heart rate levels than did the controls
(167.66 ± 10.94) (Table 2). After the process, there were significant
differences in the heart rate levels between the experimental and
control groups (p = .000); the experimental group
(119.73 ± 10.77) had significantly lower pain levels than did the
controls (131.66 ± 9.64) (Table 2).
Comparison of SpO2 levels between the groups
SpO2 levels were evaluated twice, during and after the proce-
dure. During and after the procedure, the SpO2 levels were found
to be significantly different between the groups (p = .000,
p = .041) (Tables 2 and 3).
Discussion
Studies have examined several methods to relieve pain in chil-
dren. These studies were performed and examined generally in sit-
uations such as vaccination, intramuscular (IM) injection and blood
collection. Studies to relieve pain during painful procedures
applied to children in PICUs are limited (Aydin et al., 2016;
Canbulat et al., 2014; Cerne et al., 2015; Oliveira and Linhares,
2015; Bakan 2017; Canbulat Sahiner et al., 2018; Koç and Gözen,
2015; Singh, 2012; Schechter et al., 2007). This study examined
the effectiveness of making children hospitalised in the PICU listen
to their mothers’ voices during painful procedures. It was observed
at the end of the study that the pain levels and heart rates of the
children in the experimental group during and after the painful
procedures were much lower and their oxygen saturations were
higher than were the children’s in the control group.
Exposure to painful procedures is a negative experience for chil-
dren. It has been reported that children have physiological
responses during painful procedures (Gibbins et al., 2008).
Although many studies have examined the effectiveness of a
mother’s voice on physiological variables during painful proce-
dures, these studies are generally limited to infants (Filippa et al.,
2017; Azarmnejad et al., 2015). Of the limited number of studies
examining the effectiveness of a mother’s voice during painful pro-
cedures in the PICU, this study demonstrated that the pain scores
of children who listened to their mothers’ voices were significantly
lower during and after painful procedures than were those of the
children in the control group. Children exposed to painful proce-
dures experience extreme stress and anxiety and this causes
short-term and long-term adverse effects in children (Lisi et al.,
2013; Hooke et al., 2002; Twycross and Finley, 2013; Oakes et al.,
2008). It is very important to reduce the pain level to prevent chil-
dren from experiencing the stress when faced with such events.
According to the data obtained as a result of this study, making
children listen to their mothers’ voices during painful procedures
in the PICU can be used effectively to relieve pain.
Epinephrine and norepinephrine cause an increase in heart rate
during painful procedures. The heart rates of the children in the

Please cite this article as: Ç. Erdoğan, T. Turan and B. Pınar, The effect of maternal voice for procedural pain in pediatric intensive care unit: A randomised
controlled trial, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2019.102767
 Ç. Erdoğan et al. / Intensive & Critical Care Nursing xxx (xxxx) xxx
experimental group were significantly lower during and after pain-
ful procedures compared to those of the children in the control
group at the end of this study. It can be said that the reason for this
may be that the children in the experimental group felt less pain
(Yoo et al., 2011). Further studies may benefit from the use of other
measurement methods for the heart rate, such as listening with a
stethoscope or pulse oximetry monitor.
Oxygen saturation levels of individuals are affected by many
factors, such as age, anxiety, stress level, patients’ drug use and
the degree of their participation during distraction interventions
(Walco et al., 2005). The comparison of the children in the experi-
mental group with the children in the control group revealed that
the oxygen saturation levels of the children in the experimental
group were higher. This may be because the mothers’ voices the
children heard in the experimental group helped them experience
pain-related stress less, and the children in the experimental group
exhibited a higher degree of participation in distraction interven-
tions due to hearing of their mothers’ voices.
This study revealed that a mother’s voice, the effectiveness of
which is frequently reported in the literature, has a positive effect
on hospitalised children’s pain control in PICUs. Pain management
is as important in PICUs as in other paediatric units. For this reason,
it is believed that in countries where PICUs are closed spaces as in
Turkey, it will be extremely helpful if nurses record mothers’
voices for the children and make the children listen to these voice
recordings during pain management when the mother cannot
actively participate. In countries where mothers can reach their
children actively in PICUs and where family-centred care is
applied, mothers are advised to be together with and talk to their
children during painful procedures.
Limitations
One of the limitations of the study was that the sample was
taken from the PICU in only one hospital. Another limitation of
the study was that the results of the study were limited by this
study group population due to the difference in limited visit time
of intensive care in our country. The most important limitation of
this study is the lack of blinding which only one nurse researcher
reporting the pain level (FLACC). Another limitation is that children
in the sample group may experience more anxiety/pain due to the
limited visitation time of their parents. One of the limitations is the
use of the urn method for randomisation.
Conclusions
A mother’s voice can be used as one of the methods of distrac-
tion in pain control for children hospitalised and treated in PICUs.
Moreover, carrying out new studies by using this method will be
useful for determining its effectiveness in PICUs.
Conflict of interest
No conflict of interest all authors.
Funding sources
No funding.
Ethical approval details
IRB: 60116787-020/58588
Please cite this article as: Ç. Erdoğan, T. Turan and B. Pınar, The effect of maternal voice for procedural pain in pediatric intensive care unit: A randomised
controlled trial, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2019.102767
5
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Please cite this article as: Ç. Erdoğan, T. Turan and B. Pınar, The effect of maternal voice for procedural pain in pediatric intensive care unit: A randomised
controlled trial, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2019.102767