Kangaroo Care and the Ventilated Neonate

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

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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 mothers breasts or against
the fathers chest for a non-specific period of
time.
(Kenner Lott, 2003)
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Benefits of Kangaroo Care

• Maintaining physiological stability.
• Increasing immunity.
• Optimising breastfeeding.
• Facilitating parent-infant bonding
• (Shiau and Anderson, 1997 WHO,
  1997 WHO, 2003).

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Kangaroo Care as an alternative to cots in rural
Tanzania
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In a setting as affluent as our own to what
extent should Kangaroo Care be promoted?
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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.

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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.

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Physiological Stability
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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).

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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).

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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).

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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)

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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.

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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.

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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.

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Barriers to Kangaroo Care with ventilated
neonates in practice

• 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

(Engler et al, 2002)
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(No Transcript)
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Recommendations for practice

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

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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.

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References

• Anderson, et al (2001). Kangaroo care Not just
  for stable preemies anymore. Reflections on
  Nursing Leadership. 14, 3334, 45.
• Bier et al (1997) Breastfeeding infants who were
  extremely low birthweight. Pediatric. 100
  773812.
• 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 214216.
• 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
  711713.

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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 137781
• 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.