Kangaroo Care and the Ventilated Neonate

1. Kangaroo Care and the Ventilated Neonate By Karen Black (MNursSci, RNC)

2. Kangaroo Care (also known as Skin-to Skin Contact) • Was developed by Rey and Martinez (1983) in Bogotá, Columbia as an alternative to incubator care (WHO, 2003) • Was initially defined as: “The care of preterm infants carried skin-to-skin with the mother.” (WHO, 2003) • Its key features were described as: • Early, continuous and prolonged skin-to-skin contact between the mother and the baby. • Exclusive breastfeeding (ideally) • Being initiated in hospital and continued at home • Providing small babies with the opportunity to be discharged early. (WHO, 2003)

3. Current definition of Kangaroo Care: “A form of parental caregiving where the newborn low birthweight or premature infant is intermittently nursed skin-to-skin in a vertical position between the mother’s breasts or against the father’s chest for a non-specific period of time.” (Kenner & Lott, 2003)

4. Benefits of Kangaroo Care • Maintaining physiological stability. • Increasing immunity. • Optimising breastfeeding. • Facilitating parent-infant bonding (Shiau and Anderson, 1997; WHO, 1997; WHO, 2003).

5. Kangaroo Care as an alternative to cots in rural Tanzania

6. In a setting as affluent as our own to what extent should Kangaroo Care be promoted?

7. Kangaroo Care and the Intensive Care Infant • Cochrane review states that Kangaroo care should not be routine practice in the technological setting. (Conde-Agudelo, et al, 2003) • Decision to ‘Kangaroo’ infants generally left to individual nurses clinical judgment (Nyqvist, 2004). • Many infants miss out on opportunity to consider this practice.

8. Aims and objectives • To examine the application and limitation of Kangaroo Care with intubated LBW or very premature infants requiring mechanical ventilation. • To critically examine the literature. • To provide recommendations for practice.

9. Physiological Stability

10. Transfer Technique • Indicated to be the greatest contributing factor to heat loss and increased stress, resulting in tachycardia or apnoea (Ludington-Hoe et al, 1998) • Lifting commonly associated with oxygen desaturation (Danford et al, 1983; Peters, 1992). • Physiological disruption occurred in both parent and nurse led transfer techniques (Neu et al, 2000). • Involving 2-3 nurses in transfer minimises the risk of extubation or physiological disruption (Ludington-Hoe et al, 2003).

11. Breastfeeding • The diverse range of benefits of breastmilk for premature infants are widely documented. • Admission to NICU and necessity for intubation affects decisions to breastfeed(Jaeger et al, 1997). • Those who chose to breastfeed often have difficulty establishing expression and sufficient supply during period of intubation and tube feeding(Furman and Kennell, 2000).

12. Advantages of Kangaroo Care to breastfeeding • Stimulates endocrine pathway and enhances flow of milk (Bier, 1997; Whitlaw et al, 1998). • Reduces harmful anxiety and stress emotions (Whitlaw et al, 1998). • Promotes family centred care and breaks down barriers to expression of milk (Jaeger et al, 1999).

13. Parental benefits of Kangaroo Care • Reduction in stress and anxiety improves parents perception of the infants’ admission to NICU and subsequent ventilation(Legault & Goulet, 1995). • Reduces feelings of inadequacy, anxiety and frustration experienced by fathers(Neu, 2004). • Facilitates closeness and bonding(Neu, 2004). • Case reports detail benefits in reducing complications associated with maternal eclampsia(Anderson et al, 2001)and post-natal depression(Dombrowski et al, 2001)

14. Adverse effects of Kangaroo Care • Increased stress on dislodgement of venous or arterial lines or accidental extubation. • Feelings of guilt if infant becomes physiologically unstable during Kangaroo period.

15. Evaluation of evidence • Benefits in breastfeeding, nutrition and parental satisfaction if undertaken safely. • Practice can benefit physiological stability if carried out for an appropriate length of time and utilising a safe transfer technique. • Kangaroo care can be conducive with mechanical ventilation.

16. Limits in research evidence • Compatibility of ventilation method. • Accessing haemodynamic stability. • Drug contraindications. • Limit of gestational age or size of infant. • Studies from British units. • Randomized control trials.

17. Fear of arterial or venous line dislodgement Fear of accidental extubation Safety issues for very low birthweight infants Inconsistency in technique Nurses’ feelings that their work load increased. Nursing reluctance. Medical staff reluctance Difficulty administering care during KC Staff concerns for parental privacy Lack of experience with KC Insufficient time for family care during KC Belief that technology is better than KC Barriers to Kangaroo Care with ventilated neonates in practice (Engler et al, 2002)

19. Recommendations for practice • Development of evidence based policy at Trust level. • Incorporate an inter-disciplinary approach. • Remain aware of limitations of policy implementation

20. Recommendations for education • Comprehensive education detailing the benefits and risks. • Up to date evidence based information. • Incorporated into new staff induction or learning beyond registration study days. • Encourage critical reflection on experiences of Kangaroo care with ventilated infants.

21. References • Anderson, et al (2001). Kangaroo care: Not just for stable preemies anymore. Reflections on Nursing Leadership. 14, 33–34, 45. • Bier et al (1997) Breastfeeding infants who were extremely low birthweight. Pediatric. 100: 773–812. • Bliss (2004) Available at: www.bliss.org.uk (Accessed 14.11.04 updated 01.10.04). • Conde-Agudelo et al (2003). Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. The Cochrane Database of Systematic Reviews. 2. • Drosten-Brooks, F. (1993). Kangaroo Care: Skin-to-skin contact in the NIVU. Maternal Child Nursing. 18(5): 250-253 • Danford et al . (1983). Effects of routine care procedures on transcutaneous oxygen in neonates: A quantitative approach. Archives of Disease in Childhood, 58, 20-23. Bibliographic Links External Resolver Basic • Dombrowski et al . (2001). Kangaroo (skin-to-skin) Care with a postpartum woman who felt depressed. MCN, The American Journal of Maternal and Child Nursing. 26: 214–216. • Engler, A. et al (2002) Kangaroo Care National survey of practice, knowledge barriers and perceptions. Maternal and Child Nursing. 27(3): 146-153. • Furman, L. & Kennell, J. (2000). Breastmilk and skin-to-skin kangaroo care for premature infants. Avoiding bonding failure. Acta Paediatrica. 89: 1280-1283. • Gale, et al (1993). Skin-to-skin holding of the intubated premature infant. Neonatal Network. 12(6): 49-57 • Jaeger MC et al (1997) The impact of prematurity and neonatal illness on the decision to breast-feed. Journal of Advanced Nursing. 8, 4, 112-117. • Kenner, C. & Lott, J.W. (2003). Comprehensive Neonatal Nursing. Saunders, USA. • Legault, M. & Goulet, C. (1995). Comparison of kangaroo and traditional methods of removing preterm infants from incubators. Journal of Obstetric, Gynaecological and Neonatal Nursing. 24(65): 501-506. • Ludington-Hoe et al (1998). Kangaroo Carewith a ventilated preterm infant. Acta Paediatrica. 87: 711–713.

22. References continued • Ludington et al (1999). Skin-to-skin contact effects on pulmonary function tests in ventilated preterm infants. Journal of Investigative Medicine. 47(2): 173-177 • Ludington et al .(2003). Safe criteria and procedure for Kangaroo Care with intubated preterm infants. Journal of Obstetric, Gynaecological and Neonatal Nursing. 32 (5): 579-586. • Neu et al (2000). The Impact of Two Transfer Techniques Used During Skin-to-Skin Care on The Physiologic and Behavioural Responses of Preterm Infants. Nursing Research. 49(4): 214-223 • Neu, M (2004). Kangaroo Care: Is it for Everyone? Neonatal Network. 23(5): 47-54. • Nyqvist, K.H (2004). How can Kangaroo Mother Care and High Technology Care be Compatible? Journal of Human Lactation. 20(1): 72-74 • Peters, K. L. (1992). Does routine nursing care complicate the physiologic status of the premature neonate with respiratory distress syndrome? Journal of Perinatal and Neonatal Nursing, 6, 67-84. • Shiau, S.H. and Anderson, G.C. (1997). Randomized controlled trial of kangaroo care with full-term infants: effects on maternal anxiety, breast milk maturation, breast engorgement, and breastfeeding status. Australian Breastfeeding Association, Sydney. • Smith, S.L. (2001). Physiological stability of intubated Very Low Birtheight infants during skin-to-skin care and incubator care. Advances in Neonatal Care. 1(1): 28-40. • Swinth et al (2003). Kangaroo care with a Preterm Infant Before, During and After Mechanical Ventilation. Neonatal Network. 22(6): 33-38 • Whitelaw et al (1998) Skin-to-skin contact for very low birthweight infants and their mothers. Archives of Disease in Childhood. 63: 1377–81 • World Health Organization (WHO) (1997). Thermal Control of the Newborn: A practical Guide. Maternal Health and Safe Motherhood Programme. WHO, Geneva • World Health Organisation (WHO) (2003). Kangaroo Mother Care: A Practical Guide. Department of Reproductive Health and Research, Geneva.