Written by Megan Dooley
“In New Zealand, nearly 8 out of 100 babies are born preterm and that number has been increasing annually by 2.1 per cent over the last 20 years”
(Healthy Quality & Safety Commission New Zealand, 2012, p.1).
Preterm birth and admission to the neonatal intensive care unit disrupts neonate neurobehavioral development, physiological development and interrupts maternal-infant bonding by separation from mother for long periods of time (Jefferies, 2012). “Kangaroo care is now considered a fundamental component of developmentally appropriate therapy for hospitalised preterm infants” (Ludington-Hoe, 2013, p.73). Kangaroo care has benefits and positive outcomes for both infant and mother in the neonatal intensive care unit. The goal of this paper is to critically discuss best evidence of the benefits of kangaroo care along with implications and recommendations for clinical practice. Physiological, behavioural and maternal-infant bonding benefits of kangaroo care will be investigated using evidence based literature to answer the research question.
Kangaroo care originated in Bogota, Colombia more than 30 years ago; it was developed out of urgency as an intervention to preserve infants’ body temperature due to a shortage of incubators (Feldman, 2004). Kangaroo care is the practice of skin-to-skin contact. The baby is undressed down to a nappy and placed on the mother’s breasts with a blanket supporting the baby from behind (Capital and Coast District Health Board, 2012). I became aware of this issue by talking to a nurse who practices in a neonatal intensive care unit in New Zealand. I expressed an interest in becoming a neonatal intensive care nurse, and through discussion, I found out that kangaroo care is a current nursing intervention used in neonatal intensive care units around New Zealand and the world. The rationale for me pursuing this clinical issue is to become knowledgeable on what benefits kangaroo care provides to mothers and infants so that if faced with it in future practice, I can assist in the implementation of kangaroo care with confidence. In my own nursing practice I would like to have a holistic approach. I think it is a vital part of nursing to look at all aspects of the patients being to determine health. The implementation of kangaroo care, in my opinion, is a holistic nursing intervention that can be used to benefit not only the infant, but the mother and family as well.
Kangaroo care is common in neonatal intensive care units around the world. It was first introduced in Columbia as an alternative approach to the traditional care of incubation for preterm infants, due to overcrowded nurseries and a lack of resources. It was shown to have reduced the number of mortalities and enhance mother-infant attachment (Jefferies, 2012). The literature covers many benefits of kangaroo care; physiological, behavioural and maternal-infant bonding (Jefferies, 2012; Johnson, 2007; Ludington-Hoe, 2013).
Since the first study was done on kangaroo care in Columbia in 1978, it has been found to have a soothing effect on premature infants. Mothers of infants receiving kangaroo care reported their infants being calmer than the control group and physiological stability was noted (Feldman, 2004). Feldman (2004) explains that following the introduction of kangaroo care research conducted through the 1990’s, the positive effects of kangaroo care on premature infants are highlighted. Ludington-Hoe, Hadeed and Anderson (2013) examined the physiological responses of 12 premature infants during kangaroo holding. Through this study, heart rate, respiratory rate, oxygen saturations and temperature was measured every minute during kangaroo holding and it was noted that physiological status remained stable (as cited in Johnson, 2007). Supporting this, a more recent study examined the physiological effects on preterm infants for three continuous hours of kangaroo holding compared to standard care; this study showed that through kangaroo holding, cardiorespiratory and temperature outcomes reflected clinically acceptable limits with no adverse effects for these infants (Ludington-hoe, Anderson, Swinth, Thompson & Hadeed, 2004). Additional research of Dr. Ludington has demonstrated that infants are warmer on the mother’s chest than in an incubator, infant breathing improves and quiet sleep time doubles for the infant during kangaroo holding (Johnson, 2005).
There are no adverse effects on the physiological status on a preterm infant during kangaroo holding and continued research has analysed the safety and benefits of kangaroo care in the neonatal intensive care setting (Johnson, 2007; Jefferies, 2012; Ludington-Hoe, 2013). A recent article by Ludington- Hoe (2013) states that lying on the mother’s chest is a warm and safe environment for the premature infant. The author also suggests that positioning of the baby in a prone position rather than supine is beneficial to maintain physiological stability. Kangaroo care is associated with a higher percentage and longer periods of breastfeeding, and higher volumes of breast milk expressed (Jefferies, 2012). Johnson (2007) explains that kangaroo care is used as a health promotion intervention in South Africa to provide the best opportunity for breastfeeding. Preterm infants receiving breast milk benefit by decreased incidence of infections and improved growth and developmental outcomes (Jefferies, 2012). Part of the nurse’s role is to encourage and promote breastfeeding as it is important to know the association between kangaroo care and breastfeeding for implementation in clinical practice.
Preterm birth is considered to disrupt the infant’s neurobehavioral development, which can manifest in a disorganization of the nervous system, resulting in stress to the infant and disturbances in behaviour (Jefferies, 2012). For a preterm neonate, crying is not a normal behaviour as it is for those of full term. Crying for the preterm infant means a depletion in oxygen reserves and energy and could increase the possibility of brain injury and cardiac dysfunction (Ludington- Hoe, Cong & Hashemi, 2002). This research illustrates the importance in answering infant cries quickly, more so in premature infants so that energy is conserved for growth and development. They also explain that kangaroo care is an efficient method in minimizing or preventing crying in premature infants.
Kangaroo care is also consistently shown to lessen infant response, perception and recovery from procedural pain (Ludington-Hoe, 2013). “During Kangaroo care the infant experiences maternal heart sounds, rhythmic maternal breathing, warmth and prone positioning, all of which offer gentle stimulation across the auditory, tactile, vestibular and thermal sensory systems which may modulate the perception of pain” (Jefferies, 2012, p.142). Kangaroo care is recommended by the American Academy of Paediatrics Society and the Canadian Paediatrics Society as a non-pharmacological strategy for painful procedures at the bedside to reduce the infant’s perception of pain (as cited in Jefferies, 2012).
According to Hunt (2008) early contact between mother and infant is essential in building the relationship. Preterm infants are usually separated from mothers straight from birth and cared for in an incubator, which delays physical contact (Hunt, 2008). Kangaroo care is an intervention that nurses can carry out immediately in the neonatal intensive care unit to promote maternal-infant bonding. Roller (2005) explains that mothers can often feel excluded and powerless (as cited in Grant & Kearvell, 2008).
An early study by Neu (1999) looked at the parent’s perception of kangaroo care with their preterm infant. The study found that mothers felt an intense connection towards their infant and many mothers continued with skin-to-skin contact long after discharge. Supporting this, a qualitative study was carried out by Johnson (2007) to describe the maternal benefits of skin-to-skin on premature infants in the neonatal intensive care unit. The study found that mothers felt needed and felt comfortable in holding their babies. These findings show that the benefits of kangaroo care are not restricted to just infants. Kangaroo care promotes family health at a time of stress in the neonatal intensive care environment by enabling family members to care for their newborn.
It is essential for the nurse to monitor heart rate, temperature, oxygen saturations and respiration rate during kangaroo holding for optimal safety. There is critical need for careful documentation of medical conditions of the infant and medical stability must be reached before kangaroo care is attempted (Feldman, 2004). Additionally, DiMenna (2006) suggests delaying kangaroo care for infants younger than 27 weeks gestation who depend on high humidification, infants who are to be kept sterile before surgical interventions and for infants who are not physiologically stable. Jefferies (2012) explains the importance of guidelines for the provision of kangaroo care to be available in all neonatal intensive care units. There is need for protocols on safe transfer of the preterm neonate between the incubator and parent. Knowing the gestational age, weight criteria, appropriate physiological measures, monitoring for stress and assessing readiness for both mother and infant is optimal in achieving safe practice (Jefferies, 2012). Feldman (2004) suggests the need for closer observation of the mothers mental state before and during kangaroo holding and that mothers should be encouraged to enter the kangaroo experience gradually and not expect too much too soon in the process. Nursing staff should work closely to support mothers in the application of this intervention, as it can be an emotional and scary time. Kangaroo care provides the nurse the opportunity to implement a family centered approach.
Barriers to Kangaroo care include poor staff knowledge, lack of time or resources, insufficient training and feeling uncomfortable with the process. Jefferies (2012) illustrates the importance in identifying such barriers so that successful implementation of kangaroo care can occur.
All nurses who practice in the neonatal intensive care unit would benefit from knowledge about the benefits of kangaroo care on preterm infants. As mentioned previously, barriers to providing kangaroo care include a lack of confidence, resources and education for it to be implemented. There is urgency for recommending ongoing education, support from management for resources and having safety protocols on the ward for safe and effective implementation of kangaroo care. Hunt (2008) recommends that literature should be produced for families so that they too can understand the importance of kangaroo care. Ludington-hoe, Ferreira, Swinth and Ceccardi (2003) developed a protocol for kangaroo care on preterm infants, no adverse events were reported from the study. This protocol and criteria could be adopted by neonatal intensive care units around New Zealand to ensure safe practice. The protocol by DiMenna (2006) could also be adopted to assist nurses in developing best practice guidelines.
It is clear through evidence that kangaroo care is beneficial to both the mother and infant in the neonatal intensive care unit. There is rich evidence that shows maternal infant bonding, physiological and behavioural benefits through kangaroo holding. With the use of education and support in the neonatal environment kangaroo care can be implemented safely and can have a holistic and family centred approach to nursing.
Capital and Coast District Health Board: Neonatal Intensive Care Unit. (2012) Retrieved from http://www.healthpoint.co.nz/specialists/intensive-care/capital-coast-dhb-neonatal-intensive-care/kangaroo-care/
DiMenna. L. (2006). Considerations for implementation of a neonatal Kangaroo Care protocol. Neonatal Network, 25(6), 405-12.
Feldmen, R. (2004). Mother-infant skin-to-skin contact (Kangaroo Care). Infants and Young Children, 17(2), 145-161.
Grant, J.,& Kearvall, H. (2008). Getting connected: How nurses can support mother/infant attachment in the neonatal intensive care unit. Australian Journal of Advanced Nursing, 27, 75-82.
Healthy Quality & Safety Commission New Zealand. (2012). Born too soon. Retrieved from http://www.hqsc.govt.nz/news-and-events/news/426/
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Ludington- Hoe, S. M., Anderson, G. C., Swinth, J. Y., Thompson, C., & Hadeed, A. J. (2004). Randomized controlled trial of kangaroo care: Cardiorespiratory and thermal effects on healthy preterm infants. Neonatal Network, 23(3), 39-48.
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Ludington-Hoe, S. M., Ferreira, C., Swinth, J., & Ceccardi, J. J. (2003). Safe criteria and procedure for Kangaroo Care with intubated preterm infants. Journal of Obstetric, Gynaecologic and Neonatal Nursing, 32(5), 579-588.
Neu, M. (1999). Parents' perception of skin-to-skin care with their preterm infants requiring assisted ventilation. Journal of Obstetric, Gynaecologic and Neonatal Nursing, 28(2),157-164.