Diane Hudson-Barr, PhD, RN NCCC @UNCH dhudson@unch.unc.

edu

KANGAROO CARE SKIN-TO-SKIN CONTACT KANGAROO MOTHER CARE

All photos courtesy of USIKC website

OBJECTIVE
Review the benefits of the use of Kangaroo Care in the Post-Partum and NICU Environments. Identify strategies to increase use of KC in your clinical setting.

WHAT IS KANGAROO CARE?

Kangaroo

Care, Skin-To-Skin Contact, and Kangaroo Mother Care are terms that relate to:
the holding of a diaper clad infant bare-chest to barechest, ventral-surface to ventral-surface, by the mother, father, or others.

This

snuggling of the infant inside the pouch of their parent's shirt, much like a kangaroo's pouch, led to the creation of the term "kangaroo care."

HOW DID KC COME ABOUT?

In response to the high death rate in preterm babies seen in Bogota, Columbia, in the late 1970s (70%) . Babies were dying of infections, respiratory problems, and simply due to lack of attention. Been studied since 1972 (nearly 500 references): Researchers found that babies who were held close to their mothers' bodies for large portions of the day, not only survived, but thrived. In the U.S., hospitals that encourage kangaroo care typically have their parents provide skin-to-skin contact for several hours each day

HIGHLY RECOMMENDED
WHO,

AAP, ACOG, UNICEF, CDC, MOD, and the NIH all recommend its use and deem it a scientifically sound, low cost, and a high impact developmental intervention for both baby and mother. New research by Dr Joy Lawn shows that Kangaroo Mother Care is one of the most powerful and effective ways to save preterm babies all over the world.

HIGHLY RECOMMENDED (LAWN)

Acceptance

of the KMC method is increasingly widespread and it is considered equivalent to conventional neonatal care for stable preterm infants and more parent and baby friendly. There is no doubt this intervention can save lives but the reality is that babies will continue to die unnecessarily unless we prioritize high-impact care (KMC).

HIGHLY RECOMMENDED (LAWN)

It

is evident that KMC has a substantial mortality effect compared with conventional neonatal care, and it is also evident that this mortality benefit is possible even at large scale. No matter if babies are born in Lilongwe, London or Los Angeles, preterm babies need extra care to survive. Kangaroo Mother Care is low-cost and feasible, and we now have proof it is one of the most highly effective ways to give more babies the chance to survive and thrive.

BENEFITS OF KC
Saves

lives -The latest studies show a 51 percent reduction in newborn mortality when babies (stable and less than 2 kg) were kangarooed within the first week after birth and breastfed by their mothers (Lawn, 2010).

BENEFITS OF KC TO THE INFANT

Mimics the soothing environment of the womb

receive touch, rhythm and pressure (containment) soothing and comforting sounds of parents heart beat, breathing and rhythmic rocking that baby became accustomed to

SUPPORTS NEUROBEHAVIOR

Provides a buffer against over-stimulation In an upright prone position, babies tolerate noise and activity around them much better (Ludington Hoe, 1993). Supports arousal regulation- Babies spend more time in a quiet alert state. Provides longer periods of restful sleep When carried out in a low light & quiet environment, helps babies to remain more calm and transition from one sleep state to another (Ferber, 2004). Preterm babies were found to have spent more time sleeping during Kangaroo Care (Messemer, 1997). Relieves stress /pain reactions Babies deal with pain better and cry less in response to pain (for procedures such as HS, Vit K injections, immunizations, & invasive procedures) while Kangarooed (Kostandy et al, 2008). Works better when combined with BF.

PHYSIOLOGIC BENEFITS OF KC TO THE INFANT

Regulates vital signs

Mom has thermal synchrony with infant: temperature of the mothers breasts actually change so that her baby can better maintain his own temperature. Moms temperature will change if the baby gets too cold/hot (fathers does not). This even works when twins are kangarooed (Ludington-Hoe, 2004). Flexed position that the baby assumes is a more efficient position for conserving heat. Stabilizes heart rate: less Bs & tachycardia rarely occurs Improves oxygen saturation levels (Feldman, 2003) Reduces apnea & uneven breathing: hearing parents breathing stimulates infant to imitate the pattern.

ADDITIONAL BENEFITS OF KC TO THE INFANT

Enhances lactation, the prevalence and duration of breastfeeding- With easy access to the breast, mothers experience easier let down, increased milk supply (Furman,2002). Mothers are more likely to breastfeed exclusively and have more success with prolonged nursing (Figueroa de Leon). Enhances immunological protection- If the mother is breastfeeding her baby, she will raise antibodies in response to all of the microbes that they come in contact with and transfer them to the baby (Lawn, 2010). Some antibodies can even be transferred skin to skin (Telemo, 1996). cortisol release A lack of touch or separation causes high amounts of the stress hormone to be released. High levels of cortisol may negatively impact immune function as the body may stop producing leukocytes. crying in preterms and term infants experiencing KC decreases the amount of cortisol produced.

LONG TERM OUTCOMES OF KC

Enhances growth/weight gain High cortisol levels that result from mother baby separation have a negative impact on growth hormone. With mother present to help assist in regulating the babys breathing, heart rate, and temperature, the baby has decreased energy needs and can conserve his energy and calories, and direct it toward growth. (Charpak, 1997). In an upright prone position babies also regurgitate less (Ludington-Hoe, 1993). Leads to shorter hospital stays Babies that are practicing Kangaroo Care can have up to a 50% shorter hospital stay than babies who are not kangarooed (Charpak, 1997). Improves neurobehavior outcomes- Preterm babies that were given many hours of KMC in the early weeks after birth, compared to those given little or no care, scored higher on mental and motor development tests in the first year of life (Charpak et al., 2005).

BENEFITS OF KC TO THE PARENTS

Improves

attachment - feelings of closeness with their babies (Dodd, 2005) Builds parent confidence and competenceHolding baby close reduces stress among parents & family (Feldman et al., 2002, 2003). Parents are empowered as they can do something incredibly beneficial & positive for their infants confidence that babies are well cared for sense of control Parents play more active role in babys recovery

ADVICE FOR PARENTS

Do

not smoke or wear smoke-scented clothing. Remove your bra and wear a blouse or shirt that opens in the front. (A hospital gown that opens in the front can be made available for your use.) Screens will be provided for your privacy. The baby, wearing only a diaper and hat, will be placed on your bare chest in an upright position. Cover the baby with your shirt, gown, or a blanket.

ADVICE FOR PARENTS

Now

simply relax and enjoy this unique bonding experience. Plan on holding your baby for at least one hour four or more times a week. Let your baby rest. This is not a time to play with your baby. Fathers can provide kangaroo care for their babies too. The different feel of the father's body will provide different stimulation to the baby.

NURSING CONSIDERATIONS
Inform parents as soon as posible about KC because the earlier they know about it, the increases their use of KC. 28 weeks need heating unit over them during KC to prevent cold stress. Standing transfer is much less stressful than sitting transfer. Monitor for 5-15 minutes after transfer to ensure VS returned to pre-transfer baseline. Position prone with flexed extremities.

NURSING CONSIDERATIONS
Position head in very slight extension to prevent airway occlusion. KC within the first hour of delivery and then daily promotes HM production and letdown reflex. Head caps should be worn by all 1000 g or who are 6 hours of age. Ideally should last for at least one hour (to allow for complete sleep cycle). RCT receiving phototherapy via bili blanket + KC for 1 hour/day did not adversely effect the decline in bili nor # of infants experiencing rebound (Ludington-Hoe &

Swinth, 2001).

FACTORS INFLUENCING RN USE OF KC

Johnson (2007): Survey results from 67 RNs in 70 bed Level III SCN in Delaware: Assessed physiologic stability of the infant (stated by 98.5% of nurses), Adequate staffing patterns, Maternal readiness, and Encouragement from management. Clinical Implications: Nurses in this study identified management support as an essential factor in utilizing KC, including "educational programs," "adequate staffing" (so coworkers could help if necessary), and "encouragement" from management as factors that support the practicing nurse in instituting KC.

FACTORS INFLUENCING RN USE OF KC

Engler (2002): > 1100 units received survey, > 500 completed: Major barriers: infant safety concerns, reluctance by nurses, physicians, and families to initiate or participate in KC, Many NICUs do not permit KC for certain types of infants (e.g., those on vasopressors or highfrequency ventilation), Over 60% of respondents agreed that low gestational age or weight were not contraindications.

AUDIENCE PARTICIPATION
How

(REVISED AFTER PRESENTATION TO INCLUDE RESPONSES)

have you tried to increase use of KC

Include

siblings in KC Talk to mom/family in prenatal class about KC Talk to mom/family in L&D before actual delivery Have mom KC when she is waiting for a visit from the Lactation Consultant When rounding with family, talk to them about KC (nurse leadership rounding) Design a large flyer with a kangaroo on it and the message Ask your nurse to have you Kangaroo Care

AUDIENCE PARTICIPATION
What

(REVISED AFTER PRESENTATION TO INCLUDE RESPONSES)

didnt work/Where should we focus our attention? Main response was how to keep it going beyond L&D, beyond the early stages in the NICU

RESEARCH QUESTIONS SUGGESTED BY LUDINGTON

How

can we reduce the amount of time it takes for starting KC in the fragile ELBW? What has to be done to have successful 24 hour/day, 7 days/week KC in the U.S.?

UNITED STATES INSTITUTE FOR KANGAROO CARE (USIKC)

Located at the Frances Payne Bolton SON, CWRU, Cleveland, OH The mission of the United States Institute for Kangaroo Care (USIKC) is to promote the Family Friendly Hospital Initiative and utilization of Kangaroo Care for all newborns in the Americas by providing education, resources, links to additional resources, consultation, a comprehensive annotated bibliography of all publications about Kangaroo Care from around the world, and recognition of excellence in Kangaroo Care by certification.

UNITED STATES INSTITUTE FOR KANGAROO CARE (USIKC)

The USIKC is the only authorized certifying entity in the Americas. Next course is in March/April 2013:
2 day conference Early bird $300, regular $325 Plus $75 for textbook Sponsors have applied for CE credits

www.kangaroocareusa.org/ ______________________________________________ Kangaroo Care Transfer Technique poster can be purchased from NANN for $9 each (members) or $15 (nonmembers)

CONCLUSION
Best

practice is to KC as soon as possible for as long as possible and as uninterrupted as possible! (Nyqvist et al, 2010, May Acta Paediatrica)

REFERENCES
See

USIKC site for comprehensive bibliography: http://www.kangaroocareusa.org/education.html (updated May 2012)

Johnson,

AN (2007). Factors influencing implementation of kangaroo holding in a special care nursery, MCN, 32(1), 25-29. (Engler et al, 2002). Kangaroo Care: National survey of practice, knowledge, barriers, and perceptions. MCN, 27(3), 146-53.