Kangaroo Mother care Method Science and Tenderness

1. Kangaroo Mother care MethodScience and Tenderness Module 2: The kangaroo Position • Definition • Modes of implementation • Evidence based benefits • Implementation of the Kangaroo Position • Implementation of the initiation protocol • KP implementation in delivery room, • KP implementation After C-section • KP implementation when no care is available • KP implementation In NICU • KP implementation in intermediate and Minimal care unit • Annex 1: KP implementation in high technology units • Annex 2: Transfer to KP and back in NICU

2. KMC Components • 1stKangaroo position • The infant is placed almost naked in strict upright ventral position between the mother´s breast, in direct contact with her skin, as long as possible • 2ndKangaroo Feeding and Nutrition strategy • Ideally exclusive breastfeeding to have a weight gain similar to the growth during the intra uterine life (15 g/Kg/day )until full term • 3rdEarly Discharge and strict ambulatory follow up • Discharge in kangaroo position regardless of weight and gestational age when the child is able to coordinate sucking, swallowing and breathing , gaining weight for 3 days and have parents informed , trained and ready to come to follow up visits

3. Kangaroo Position : the Distinctive Hallmark of KMC • The cloth support helps to prevent the child’s airway from being obstructed and developing obstructive apneas • The baby may be fed at any time, while and still in KP • Any other person (e.g. the father), can share the mother role, carrying the baby in KP • The provider must sleep in a semi-sitting position (30°) • The KP is maintained until the baby no longer tolerates it • Reference definition of the kangaroo position (KP) : The infant is placed almost naked (except hat, nappy and socks) in strict upright ventral position between the mother´s breast, in direct contact with her skin, under her clothes, 24 hours a day

4. The Kangaroo Position • The kangaroo position is the distinctive hallmark of the Kangaroo Mother Care Method • The kangaroo position has been the basis of parental involvement in the care of their preterm and/or low birth weight infant and is crucial for the humanization of care in neonatal units

5. Conditions to use of the Kangaroo Position Implementing KP in maternities  and Neonatal Units requires preparation, motivation and training of health and administrative staff : • Need of a clear open door policy 24h/24h : Parents should: • Have easy and rapid access to the hospitalized child • Be informed about hand washing and dressing policies • Have access to appropriate furniture, reclining chairs or equivalent to stay long periods of time with the child • Have access to food, restrooms, etc. • To reduce separation between mother and infant maternities and Neonatal Units staffs must be : • Flexible • Family friendly ,inviting and supporting parents actively • Trained and have good communication skills

6. Initiation of the Kangaroo Position • Initiation as soon as it is possible and prudent to do so and if the child is stable able to tolerate it: • Having stable vital signs, • No bradycardia, • No hypoxemia when manipulated, and • Not presenting primary apnea or, if present, apnea is controlled • Initiation could be: • Immediately after birth (“healthy “preterm infants) and alert mother, or • Later when the child is able to tolerate it and the mother alert and willing

7. Implementation of the Kangaroo Position • Continuous kangaroo position • The child is placed in kangaroo position 24/24 hours, until he can regulate temperature and ‘asks to be removed’ from it • Mother, father usually share the time and are the main providers of the kangaroo position ( grandparents , siblings can also participate, if trained) This mode of implementation is considered ideal, since it limits or avoids separating the child from his mother while in incubator • Intermittent kangaroo position • The child is placed in kangaroo position for short periods of time, one or several times a day for an uneven number of days It may be the only kangaroo position implementation mode or an adaptation process , leading to continuous kangaroo position according to the child’s status and the mother’s health and availability

8. Benefits of the Kangaroo Position Since late 1980’, numerous studies in Neonatal Units and during follow up visits, preferably randomized controlled trials (RCT)conducted both in developed and developing countries documented the short and long term effects of the Kangaroo Position for the child, the mother, the family and the health facilities

9. Global Benefits of the Kangaroo Position • The kangaroo position fosters the progressive mother-infant inter-relation • Mother-Infant bond facilitates the main adaptations following birth: • Physiological stability of the infant • Immediate breast feeding • minimizes maternal stress and depression due to oxytocin release • Neurobehavioral organization • Themotherbecomesan active participant in thechildstabilizationprocess • TheKangaroo position increasesthemother’sself-esteem and herconfidencetocareforherchild

10. Kangaroo Position and Thermo Regulation Preterm / LBW infants can not regulate their temperature, they need to be in a neutral thermal environment to maintain adequate body temperature without extra energy expenditure • Both kangaroo position and incubator can provide a neutral thermal environment safely and effectively • When healthy preterm infants are placed in Kangaroo position, the infant body temperature rises • At least 16 studies confirm temperature regulation during kangaroo position in a stable infant is as efficient as thermoregulation in an incubator Ludington-Hoe, Hashemi, Argote, Medellin, & Rey, 1992

11. Kangaroo Position, Heart & Respiratory Rates • In stable preterm infants in Kangaroo Position or in incubator the heart rate is similar and within the normal Meta-analysis of 23 studies conducted with stable preterm infants, monitoring their heart rates in incubator, in kangaroo position and then back to the incubator, showed that variability of heart rates in those three moments was not significant and it remained within normal Acolet, Sleath, & Whitelaw, 1989 ; Wieland, Bauer, Bisson, Versmold, 1995 Clifford& Barnsteiner, 2001 • 2011, Cochrane Meta-analysis, confirmed that the respiratory rate of preterm infants in kangaroo position is lower, but normal, than in incubator Anderson, Moore, Hepworth, & Bergman 2003

12. Kangaroo Position, Heart and Respiratory Rates Regulation • Heart and respiratory rates of preterm infants remain within normal limits during kangaroo position and are more stable than in incubator. Bergman, Linley, & Fawcus, 2004

13. Kangaroo Position and Gastro esophageal Reflux There are no studies that evaluate the relationship between kangaroo position and the incidence or severity of gastro esophageal reflux But • Prevention and management of Gastro esophageal reflux recommends to maintain the child’s head above the level of the abdomen • The kangaroo position is similar to the generally recommended anti-reflux position • Kangaroo Position does not increase the risk of Gastro esophageal reflux

14. Kangaroo Position and Oxygen saturation • Oxygen saturation may increase between 2 - 3 % during kangaroo position as compared with the incubator even during painful procedures Bier, Ferguson & al, 1996 • The evidence helps to confirm that oxygen saturation is variable, but remains within acceptable clinical standards. Ludington-Hoe, Morgan, & Abouelfettoh, 2008)

15. Kangaroo Position and Apneas Controlling the position of the child’s head and neck as in Kangaroo position is essential in order to guarantee the stability of breathing and avoid apneas due to obstruction of the air way • There is no direct evidence that the kangaroo position prevents the incidence or severity of episodes of apnea of the prematurity • In short periods and in stable patients, the frequency of apnea and periodical breathing are similar to those observed in the same children while in incubators • Evidence has demonstrated that newborns in the kangaroo position doesn’t have an increased risk for apnea

16. Kangaroo Position and Stress and Pain • Premature infants placed on the mother’s chest in kangaroo position are observed to be more relaxed, calmer, and able to sleep more easy Ludington-Hoe, Johnson, Morgan, & al., 2006 • Maintaining the child in kangaroo position during painful procedures, has demonstrated to reduce the intensity and duration of subsequent crying Kostandy, Ludington-Hoe, Cong, Abouelfettoh, Bronson, & al, 2008 The American Academy of Pediatrics recommends using the kangaroo position in order to reduce the intensity and duration of the reaction triggered by mildly to moderately painful procedures Anderson, Moore, Hepworth, & Bergman, 2003

17. Kangaroo Position and Breastfeeding • Researches demonstrated that mothers who are in skin-to-skin contact with their children have more milk than those in the control group Bier A. , Ferguson, Liebling, & al., 1995; Conde-Aqudela,Diaz-Rossello,&Belizan, 2003 • 98 % of preterm infants placed in kangaroo position 13,5 hours a day received exclusive breast milk at 40 weeks gestational age, as compared with 76 % of those who were not in kangaroo positionSuman, Udani, & Nanavati, 2008 • 55% of infants weighing less than 1500 g, was breastfed at six weeks in skin-to-skin contact groups compared with 28% of those not in skin to skin contact Whitelaw, Heisterkamp, Sleath, Acolet, & Richards, 1998 • Breastfeeding up to 5,08 months in skin to skin group compared with 2,05months in non skin to skin group Hake-Brooks & Anderson, 2008;Moore & Anderson, 2007 Moore, Anderson, & Bergman, 2007

18. Kangaroo Position and Neurologic Development and Sleep • The Kangaroo Position fosters early neurologic development in the preterm infant, improving behavioral organization: • Better organization in the sleep-wake cycles ++ • Better quality of sleep ++ • Maturation of neurologic and psycho-motor functions as measured by standardized tests • A greater complexity in brain has been observed in 32 to 40 weeks of gestational age placed in kangaroo position, as opposed to those who were not • 5 regions of the right hemisphere show greater maturation in children placed in kangaroo position Ludington-Hoe, Morgan,Abouelfettoh, 2008

19. Kangaroo Position and State of Alertness Hospital stress impairs the preterm infant's neurobehavioral outcome • It has been demonstrated , that the Kangaroo Position minimizes the negative impact of hospital stay on development Collados-Gómez, Aragonés-Corral, Contreras -Olivares, García-Faced, & al, 2011 • Kangaroo position improve the quality and duration of the periods of deep sleep++ • Children in kangaroo position cry less than in the incubator. Lehtonen& Martin, 2004;Messmer, Rodriguez, Adams, & al., 1997 McCain, Ludington-Hoe, Swinth, & Hadeed, 2005 • The kangaroo position used 5 times a week, for more than 30 minutes increases the states of alertness and attention of children evaluated at 37 weeks of gestational age, 6 and 12 months Chiu & Anderson, 2009

20. Implementation of Kangaroo Position (1) Use of a standardized protocol based on scientific evidences for adaptation and implementation of the kangaroo position to maximize the benefits for children and parents and to limit the risks • Information of mothers/parents: It is fundamental to prepare parents, especially mothers before implementing the KP • If risk of preterm delivery the benefits of the position must be repeated to motivate the mother to be with her child as much possible • All practical aspects of visits or prolonged/permanent stay during the child’s hospitalization should be explain to parents 2.Identification of beneficiary dyads mother-infant to KP:A member of the team usually a nurse, identify, at an early time, the infants who could benefit from the kangaroo position • In delivery room , in immediate post partum (mother and infant rooming in together), or in neonatal unit or nursery The mother is the ideal and main provider of the KPbut if she is unavailable, the father or any family member can immediately begin the kangaroo position

21. Implementation of Kangaroo Position (2) 3.Assessment of clinical status of infant and mother : the situation of infant and mother must be evaluated to decide to begin the KP • The ideal is to begin as soon as possible, if the baby is close to term and the mother is alert, KP starts in the delivery room 4.Adequate clothes for mother and infant • Mother/kangaroo provider must wear clothes with frontal access • A support system must be provided in order to hold the baby(Lycra™ girdle or band) • The infant should be naked except a cap ( wool or cotton) , a sleeveless cotton shirt open in the front, socks and a diaper 5. Placing the infant in Kangaroo position requires trained staff • The mother must hold him by placing one hand on the neck and back, with her fingers under his chin, the other hand is placed under the baby’s buttocks • The kangaroo baby is in upright position and ventral decubitus, with his body and head against the mother’s chest, in a” frog-like position”

22. Implementation of Kangaroo position (3) 6. Maintaining Kangaroo position and feeding • The kangaroo baby must always be kept in kangaroo position, safe for diaper change and breast feeding • During breastfeeding, the lateral position is recommended allowing skin-to-skin contact • The child should be in skin-to-skin contact, ideally 24 /24 hours • The kangaroo provider must sleep in a reclined position, of at least 30º 7. Monitoring the adaptation to the kangaroo position for infant and mother to maintain or to interrupt it • Assess the baby for the regularity of breathing, state of alertness, color, general aspect, posture, apparent comfort or discomfort, sleep and alert periods in kangaroo position • Assess the mother’s attitudes, tolerance and emotional state • Monitoring of adaptation of the kangaroo provider-child dyad must be done by a trained staff under the supervision of the pediatrician

23. Eligibility criteria for Kangaroo Position at Birth (In delivery room or after caesarian section) • The child is stable: • All vital signs and other physiological parameters (except temperature) are within normal ranges, during manipulation to place and keep him in kangaroo position • A kangaroo Provider, ideally the mother is identified • Free from fever, contagious , neurological or mental diseases • Alert, recovering from general anesthesia • Informed about kangaroo position • Willing to implement Kangaroo position • In case of mother after C-section, surgery or illness : If the mother cannot provide kangaroo care: • The father or a substitute can a kangaroo provider from birth • A picture of the child may be taken and given to the mother • The mother will come to the NICU as soon as possible and if she is transferred the infant will be brought to her

24. Kangaroo Position when no Resources are Available Refers to a premature delivery or the birth of a LBW infant, in a rural community or hospital, without special equipment and without specialists to care for the infant • If possible transfer preterm or LBW infants in kangaroo position to a health institution with the adequate equipment and staffing • If transfer is not possible: - Dry thoroughly the infant - Place the infant in kangaroo position , protected by mother clothes and blanket - Give colostrum then breast milk with a dropper, a spoon or a catheter to avoid hypoglycemia The kangaroo position offers good temporary protection against hypothermia, primary apneas of prematurity and hypoglycemia but will not treat pathologies

25. The Kangaroo Position in the Neonatal Intensive Care Unit • The advantages offered by the kangaroo position (increasing physiological stability, increasing milk production, reducing risk of nosocomial infection, decreasing pain and stress, improving brain maturation and neurobehavioral development ) as well as the possibility of avoiding separating the infant and parents ( decreasing maternal anxiety , improving bonding with the parents making them primary and active part of their child’s recovery) are good reasons to implement it in NICU in stable infants • If the infant is in a critical state, the kangaroo position may be inappropriate The decision to adopt the position must be made based on local experience, local protocol and always with authorization and close supervision of the neonatologist/pediatrician

26. Parent preparation in case of NICU hospitalization • All parents must be informed : • Of any risk during the pregnancy creating a risk of premature delivery • Of the possibility for the infant to be admitted to the NICU and the benefit of it • About the therapeutic value of the kangaroo position when it will be possible • Parents should be familiarized with medical equipment and staff • It is crucial to explain to parents the reasons and aims of procedures implemented on their infant • As much as possible, activities, such as tube feeding, diaper change, blood samplings, intravenous injections and thoracic auscultation must be performed on the child in kangaroo position

27. Preparation of Parents to Kangaroo Position in NICU • Offer appropriate information on how the kangaroo position is initiated to prepare parents to make of this contact a pleasant, positive and unforgettable situation • Determine whether the parents are eligible to begin the kangaroo position based on the assessment of the following aspects • Parent health including emotional state & anxiety management • Expressed will to begin kangaroo position • Knowledge about KMC • Decision to breast feed • Available time

28. Preparation of Health teams to implement Kangaroo Position in NICU • The health team must be sensitive not only to the newborn but also to his family • Having families involved in their baby’s care improves the quality of care, making care more humane raising feelings of satisfaction and competence in the medical team • The NICU health team must work according to their own protocols , requirements and skills • Defines eligibility criteria and contraindications • The team must: • Acquire the ability to implement the kangaroo position, • Be prepared and able to teach the parents to detect alarm signs • Receive permanent update on the development of the KMC Method

29. Eligibility criteria for Kangaroo Position in NICU Eligibility criteria for kangaroo position in NICU result of I mplementingthe KMC in Neonatal Units in Bogota (Colombia) • Preterm infants ≥ 30 weeks are eligible for KP if they have stable vital signswithin normal range at rest Some anomalies in vital signs may be present not preventing KP : • Tachycardia resulting from agitation • Bradycardia between 85-100 beats/min with spontaneous recovery and not more often more than 1 to 3 times in an hour. • Respiratory pause lasting less than 10 seconds less than 3 times per hour without desaturation • Desaturations, up to 85 %, with spontaneous oxygen recovery • Tolerance to manipulation quick recovery when manipulation is over • Oxygen(hood or nasal cannula) • Blood gases: within normal parameters

30. Contraindications for Kangaroo Position in NICU (1) Kangaroo position must not be started in preterm infants presenting physiological instability or a deterioration of the clinical condition and vital signs in the last 24 hours: • Moderate hypothermia while in incubator • Anomalies in the blood pressure ( hypotension or hypertension) • Bradycardia < 85 beats/min of any duration or heart rate 85-100 beats/ min more than 4 times per hour • Apneas with a desaturation < 85 % or any respiratory pause > 10 seconds or that requires stimulation • Any desaturation < 85 % • Physiological instability when manipulated

31. Contraindications for Kangaroo Position in NICU (2) • Difficult position of venous or arterial access which makes them unstable (central catheters, arterial lines, umbilical arterial catheters, thoracic tubes) • Use of vasopressor drug • Mechanical ventilation with increasing parameters in the last 24 hours, fluctuation of the ventilation parameters • Life-threatening medical conditions in the last 24 hours • Intracranial hemorrhage grade III-IV • Cardiorespiratory arrest • Clinical signs or laboratory parameters of sepsis • Immediate post-operatory period • Abnormal blood gases • Compromised neurological state due to lethargy and severe hypotonia

32. Transfer from Incubator to Kangaroo Position of Infant with Assisted Ventilation The easiest way to do this transfer is by standing and picking the child up • The other parent or the nurse disconnects the ventilator from the tracheal tube before the transfer and reconnects it as soon as kangaroo provider sits down with the infant • During the transfer, 1 or 2 persons (depending on the number of tubes and lines connecting the infant to the monitor, ventilator or infusion pumps) holds and secures the ventilation tube and lines to the baby’s clothes with adhesive tape • The mother must have mirror to observe the baby without moving him • A nurse should support and monitor the transfer until the parents are able to do it on their own

33. The Kangaroo Position in Intermediate and Minimal Care Units In the Intermediate or Minimal Care Units the KP can be up to 24 hours or the discharge in KP can be proposed if possible • Eligibility criteria : Infants physiologically stablefor at leastthelast 24 hours , evenif: • Oxygen ( chamber or nasal cannula) with a normal saturation while in the position • Parenteral fluids adequately held in place • Partial or total oral feedings, even with gavage • Not eligible infants • Infants with open wounds or important skin lesions • Infants under continuous phototherapy with no biliblanket • Infant with unstable metabolic situation

34. Transfer from incubator to Kangaroo Position Parents prepare the infant for transfer by holding him, in the incubator, softly with their hands for a while, before picking him up • Transfer while standing: The position provider leans slightly forward, picks up the infant in a flexed position, places the child in kangaroo position on his chest and returns to the chair/bed, sitting or reclining in a comfortable position • Transfer while sitting: A nurse or the other parent picks the baby up, maintaining support in a flexed position for arms and legs and places him in kangaroo position on the other parent’s chest, once he or she is seated

35. Transfer in Kangaroo Position • Transportation of newborn, rapidly and under optimal conditions, protect and often to safe the infant’s life • To transport “stable “ infant in kangaroo Position is an effective alternative in case of scarce or non-existent specialized transportation • It is inappropriate to transport in Kangaroo position critically ill children

36. Conclusion • The kangaroo position has been the basis of parental involvement in the care of their preterm and/or low birth weight infant and is crucial for the humanization of care in neonatal units