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
Researcher(s) Type of Study Sample group Findings
Drosten-Brookes (1993) case study 2 ? Infants responded to Kangaroo care with increased quiet sleep and decreased Oxygen requirement. ? Highlight possible benefits and need for further research.
Gale, Frank Lund (1993) Quantitative 25 ? During KC period pulse, oxygen and respiratory rate remained within normal parameters for infants of 30/40 or gt1.2kg. ? Infants lt30/40 or lt1.2kg showed signs of restlessness, tachycardia and decreased oxygenation during prolonged kangaroo care.
Ludington-Hoe, Ferreira Goldstein (1998) case study 1 ?a 27-day old neonate weighing 894g received SIMV at a rate of 12 breaths per minute whilst receiving Kangaroo Care for 45minutes.
Ludington, Ferreira Swinth (1999) Quantitative 12 ?The physiological observations of Infants lt1kg remained stable during KC and decreased oxygen requirement.
Smith (2001) Quantitative 14 ?Infants oxygen requirements increased and body temperature dropped.
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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.