The Effect of Non-pharmacological Methods on Pain

In the study, the groups of the babies will be determined by a lottery method. Preterm babies included in the study will be randomly assigned to three groups using a closed envelope method. To ensure equal distribution of babies according to gestational age, two sets of envelopes will be created for 30-33+6 weeks and 34-36+6 weeks. An independent nurse working in the NICU will be asked to select a paper from the closed envelope corresponding to the baby's gestational week. Based on the number written on the selected paper, the baby will be included in the study group. The groups will be: Group 1 - facilitated tucking position + oral breast milk, Group 2 - kangaroo care + oral breast milk, and Group 3 - control group. After the babies are assigned to the groups, data collection will begin.

Before data collection, the researcher will provide necessary information about the study to the families of the newborns who meet the sample selection criteria and will answer their questions. After obtaining written consent from the parents of the babies who agree to participate, they will be included in the study. The information in the introductory information form for the newborn and parents will be recorded by the researcher.

• Breast Milk Administration Procedure During tape removal, babies will be given breast milk orally. The amount of milk given to the baby will be adjusted according to gestational age (1.5 ml for 30+1-32 weeks; 2 ml for 32+1-36+6 weeks) (Peng et al., 2018).
• Tape Removal Procedure The same product (medical tape suitable for the baby and causing minimal tissue trauma) will be used to effectively secure medical devices. To remove the tape, moistened gauze or saline pads will be used to gently and slowly remove it parallel to the skin surface horizontally.

• GROUP: Interventions for the Facilitated Tucking Position + Oral Breast Milk Group Preterm newborns in the facilitated tucking position + oral breast milk group will be placed in the facilitated tucking position by the researcher 15 minutes before the tape removal procedure and given oral breast milk 2 minutes before the tape removal procedure. The facilitated tucking position will be maintained until 2 minutes after the tape removal procedure. To prevent heat loss, preterm newborns will be positioned in the right lateral position inside the incubator by using the incubator windows without opening the incubator lid, with their arms and legs brought to the midline in the facilitated tucking position.

• GROUP: Interventions for the Kangaroo Care + Oral Breast Milk Group Preterm newborns in the kangaroo care + oral breast milk group will receive kangaroo care from the researcher 15 minutes before the tape removal procedure to alleviate pain; oral breast milk will be given 2 minutes before the tape removal procedure. The mothers of the babies in this group will be seated in the neonatal intensive care unit (NICU), and a nurse will place the newborn upright between the mother's bare breasts, slightly extending the head to facilitate breathing. The legs will be spread under the mother's chest and positioned in flexion. The back will be wrapped with extra fabric up to the ear level to prevent heat loss. During the contact, the mother will be allowed to talk to, move, or engage in other activities with her baby, but feeding will not be permitted. After ensuring the comfort of both the newborn and the mother, this position will be maintained for 15 minutes before the tape removal procedure. Subsequently, the nurse will perform the tape removal while the newborn is in the kangaroo care position, and the mother and baby will remain in kangaroo care for an additional 2 minutes. Once data collection is complete, kangaroo care can continue based on the mother's wishes, the baby's condition, and clinical circumstances.

Interventions for the CONTROL Group Newborns in the control group will undergo the routine nesting procedure of the clinic. All newborns will be placed in the lateral position. For ethical reasons, if babies cry during or after the procedure, gentle touch and verbal comfort will be provided to them.

In all experimental groups, heart rate, respiratory rate, oxygen saturation values, and PIPP-R scores will be measured and recorded at the following time points:

• 0 minutes: Measurements will be taken and recorded immediately before any intervention while the baby is in a resting position. Then, depending on the baby's group, either the facilitated tucking position or kangaroo care will be applied.
• 13 minutes: Measurements will be taken and recorded immediately before giving oral breast milk.
• 15 minutes: Measurements will be taken and recorded during the tape removal procedure.
• 17 minutes: Measurements will be taken and recorded 2 minutes after the tape removal procedure, while non-pharmacological interventions continue.
• In the control group, similar measurements and assessments will be conducted at the same time intervals and recorded.

The PIPP-R scores of all groups will be recorded on a data assessment form by two independent evaluators based on video recordings.

Inclusion criteria

• Gestational age between 30 and 36+6 weeks
• The newborn not having undergone a painful procedure at least 1 hour before the intervention
• Not having received analgesic and/or sedative medication in the last hour
• Presence of maternal breast milk
• Not having received oral or enteral feeding in the last hour
• Not receiving continuous positive airway pressure (CPAP) or oxygen therapy

Exclusion criteria

• Having ventilator support
• Having a congenital anomaly
• Undergoing continuous sedative treatment
• Having a congenital malformation that could cause asphyxia and affect breathing
• Having intracranial hemorrhage