Kangaroo Care: the Use of Improved Technology and Methods - Research Paper Example

 Introduction Kangaroo care (KC) is defined as “early, prolonged and continuous skin-to-skin contact between a mother and her newborn” (Cattaneo 1998, p.976). The rationale for choice of this topic for a critical literature review is the current new realization on the benefits of kangaroo care in the care of preterm, very ill infants. Research studies indicate that KC is best used for full-term, healthy infants. However, new evidence supports the use of KC for stabilising the preterm ventilated infant. KC may best be started soon after birth, without any delay for the baby to first achieve stabilisation. Thesis Statement: The literature review aims to critically analyse contemporary research evidence on the benefits of KC for premature, ventilated infants, to identify guidelines on stability in ventilated infants, and to determine the optimal method of transferring intubated neonates to the mother for kangaroo care, and back again to its incubator. Further, the purpose of this paper is to determine the limitations of kangaroo care, barriers to using the intervention, and a standard for care provision. Literature Review The term “kangaroo care” or skin to skin care is derived from its similarity to the way marsupial mothers nurture their newly born young. During kangaroo care, mothers hold their diaper-clad infant skin-to-skin, and upright between their breasts. In this position of extrauterine containment, the infant is held in a flexed position, and is covered by the parent’s clothing or a blanket (van Zanten 2007). The Use of Kangaroo Care with Preterm, Ventilated Infants Nursing care of critically ill and low birthweight infants is complex, demands expensive infrastructure and highly skilled staff. Oxygen is important for metabolism and physiological functioning, and ventilation is regularly used in preterm infants whose lungs are immature and unable to work at the required capacity. Infants can receive kangaroo care whilst on ventilation. During the skin-to-skin period, the infant’s oxygen saturation level is increased, its requirement for oxygen declines, and the process of respiration gets stabilised (Hunt 2008; Dodd 2002). Ludington-Hoe (2003) conducted kangaroo care with an unreported number of mechanically ventilated infants who weighed less than 600 grams and were less than 26 weeks gestation at birth. The researchers found that neonates who were mechanically ventilated appeared to respond to kangaroo care particularly well. Though no untoward events have been reported in research, the lack of inconclusive evidence is stated by some practitioners to be the reason for not recommending kangaroo care (Dodd 2002). This is supported by Fischer (1998) who states that during KC there were no significant changes in oxygen saturation and consumption. Some contrasting evidence on KC for ventilated infants are that Ludington (1994) state that empirical validity of kangaroo care’s safety with infants receiving ventilation is unavailable. Further, Ludington-Hoe (1998) assert that kangaroo care begins only after the baby no longer requires further support from the neonatal care unit, although intermittent skin to skin contact for ventilated infants may have been used. Hence, in practise, critically ill neonates may not be administered kangaroo care because of a lack of evidence and protocol for this type of care. On the other hand, WHO (2003) and Ludington-Hoe (2003) recommend KC for infants age 28 weeks or above, and include infants who are mechanically ventilated. However, Feldman (2002) states that kangaroo care can be beneficially provided to infants below 28 weeks. Moreover, kangaroo care increases parental confidence in caregiving and sensitivity to the infant’s cues. An important factor in the care of ill, preterm infants is that, early contact with the mother is vital for initiating their relationship. Preterm infants and mothers are often separated at birth, and their physical contact is significantly delayed. This may be an impediment to early physiological stabilisation of the infant, and development of the mother infant relationship (Miles 2006; Roller 2005). Ludington-Hoe & Swinth (1996) reiterate that kangaroo care provides developmental care through containment, prone positioning and gentle touch; self-consoling/ soothing by nesting, and parental caregiving and holding. The potential for KC to make contributions to stabilisation and neurobehavioral development is increased if the practice begins early. As given above, several research studies give conclusive evidence that the critically ill, preterm, unstable infant on ventilation and intubation are the primary candidates for receiving kangaroo care. Some of the important benefits of kangaroo care are: provision of adequate warmth to the ill neonate by energy conservation through close contact with the mother, regularisation of heart beat and respiration, reduction of apnea, adequate oxygenation, deep sleep for longer durations, alert inactivity, less crying, less cranial deformity, no increase in infections, shorter length of hospital stay and enhanced weight gain. Kangaroo care facilitates smooth transition to breastfeeding, and is beneficial in increasing the production of maternal milk (Dodd 2002). Cong (2009) conducted a randomised cross-over trial on infants’ response to pain stimulus through heel stick intervention. The sample consisted of 14 preterm infants, 30-32 weeks gestational age and less than 9 days postnatal age. Heel stick is the most painful procedure for preterm infants in the neonatal instensive care unit. The study found that infants experienced better balance of behavioural state, heart rate, recovery period and other autonomic responses to heel stick pain in kangaroo care than in incubator care. Hence, KC is believed to be helpful in lowering physiologic response to painful procedures in preterm infants. Guidelines on Stability in Ventilated Neonates Kangaroo care stabilises preterm infants and prevents their admission to NICU (Neonate Intensive Care Unit). An infant’s adaptability to its environment is based on its level of stabilization of physiologic and behavioural responses (Ludington-Hoe & Swinth 1996: 691). A preterm infant’s state stability is supported by sleep induced by the warming received from kangaroo care. The upright position of kangaroo care is beneficial. Easier breathing and relaxation result from improved outward recoil of the chest, diaphragm and lung mechanics. Improved oxygenation results from prone positioning which supports the chest wall and allows gravitational forces to improve ventilation. Gale (1993) studied 25 intubated infants of different weights and post-conceptional ages. Low birth weight infants with respiratory distress syndrome who received KC experienced increased oxygen saturation and improved body temperature, over that of infants in incubators, who did not receive KC. Similarly, van Zanten (2007) conducted a case control study of 34 ventilated preterm infants divided into sample group and control group. He found that as compared to the control group, KC protected and stabilised vital parameters during and after intervention as measured by heart rate, oxygen saturation, respiratory rate and arterial blood pressure. Fischer (1998) found contrasting evidence from studying the stability of the cardiorespiratory system of 20 preterm boys and girls, during maternal KC as compared to incubator. Heart rate, respiration, oxygen saturation and total stability did not change significantly during the pre-test, test and post-test conditions. However, inidividual infants may respond to KC with improved or impaired stability. Cardiorespiratory stabilization in girls was seen to be higher than in boys, both during KC, as well as in the incubator. Further studies would help to determine the best position for the baby during KC. Kangaroo care has been successfully administered by parents to infants supported by bilateral chest tubes, with multiple lines, and on ventilators including high frequency oscillatory ventilation (HFOV). Kledzik (2005) states that neonates suffering from frequent and significant apnea, bradycardia or desaturation of oxygen have been considerably benefited by kangaroo care. They experience more stabilisation of vital signs when supported by the contact of skin-to-skin holding. The goal of stabilisation is the infant’s smooth transition in the range between sleep and aroused states. Respite from environmental stimuli comes from the quiet sleep state, though in preterm infants, 60% to 70% of sleep time is active sleep. Hence interventions that decrease active sleep and maximise quiet sleep are needed to protect the infant from environmental stimulants (Ludington-Hoe & Swinth 1996: 696). Optimal Transfer Technique The infant’s motor disorganisation and an increase in maximum heart rate outside the normal range occur during transfers, though axillary temperature may not change significantly. Positioning the head 90 degrees to one side may contribute to intraventricular hemorrhage (IVH) in the very immature infant at a vulnerable stage. Midline head positioning and keeping the baby in the same plane during slow and supported movement decreases the risk of IVH (Pellicer 2002). Preparations for transfer can begin at the end of the last caregiving session before the planned time of kangaroo care. Dress the infant in a diaper only, position him in flexion, and contain him with a swaddled blanket or deep nesting. For single-person transfer, position the baby supine. For two-person transfer, the infant should be placed in prone or side-lying position. For stabilisation, Kledzik (2005) suggests containment and boundaries, and no additional stimulation. A patent airway should be assured, if necessary by suctioning. Stability of the endotracheal tube (ETT) should be assured, as also continuous positive airway pressure (CPAP) or nasal cannula. It is beneficial to review with the parents the infant’s responses to handling and behavioural cues. The parent should be seated comfortably in a semi-reclining position. The greater the reclining position, the more gravity works to maintain correct infant position and function of the ETT (Kledzik 2005). When the neonate is transferred from the incubator to kangaroo care, the infant experiences stress and its oxygen requirements may increase. However, this elevated need for oxygen settles down quickly with the onset of skin-to-skin care, state Ludington-Hoe (2003). Usually, the newborn is gently placed upright on the parent’s chest. Alternatively the cradle position, in containment, supported by parent’s hands provides warmth and skin contact. It allows the infant to keep his head in midline and remain in a horizontal plane, to maintain cerebral hemodynamics. All tubes and equipment should be supported during the move, conveniently placed and checked for normal functioning. The ventilator tubing should pass over the parent’s shoulder, and be taped securely in place. Sessions from one to five hours a day facilitate stabilisation (Kledzik 2005). Limitations of Kangaroo Care For successful outcomes, the basic requirements for kangaroo care are: a supportive environment and adequately trained health personnel (Wallin 2004). Nirmala (2006) asserts that the availability of nurses with ability to support and motivate the mothers is crucial. Other limitations to KC are parental hesitation to handle the critically ill newborn, or parental anxiety about close bonding in case the ill, preterm infant does not survive. Further, kangaroo care involves the need for gentle handling and low level stimulation. Very small, ill neonates tend to slouch due to lack of mature muscle tone. This may displace the ventilation received by the infant, which can lead to distress. Hence appropriate briefing of mother, nurse vigilance and skills are essential. According to Smith (2007), there is likelihood of hyperthermia caused by maternal heat transfer, hypoxemia resulting from poor positioning of the infant’s head, accidental extubation of the ventilated infant or inadvertent removal of central intravenous lines. Moreover, lack of access to evidence on the safety of kangaroo care intervention with ventilated infants is a drawback to implementing KC. Barriers to Kangaroo Care Despite proven benefits, constraints of time, space and lack of a workable protocol prove to be barriers to the regular use of kangaroo care in neonatal units (Hunt 2008). Charpak & Ruiz-Pelaez (2006) add that healthcare professionals consider KC to represent extra work for staff. Also, a culturally determined barrier to direct skin to skin contact between the infant and the mother is sometimes present. Mothers may have inadequate privacy during the time of KC, due to exposure to strangers while learning the techniques. Further, there may be objection to the infant’s use of diapers due to cultural, religious or economic reasons. Here, feasible solutions have to be found. Lack of sufficient information and knowledge of healthcare personnel, is also a barrier, since the staff may follow their own assumptions on procedure (Charpak & Ruiz-Pelaez 2006). Standard for Care Provision A protocol and standard for implementing kangaroo care is outlined, as drawn from the above analysis. First, infant readiness and hemodynamic stability have to be verified using a multidisciplinary team approach, including the parents. However, research evidence has shown, as given above, that even critically ill intubated infants fare better with kangaroo care, and start thriving earlier than without KC. Hence, DiMenna (2006) supports the elimination of preliminary stabilisation, and advocates preparation of the ventilated infant for kangaroo care, soon after birth. Next, education and ensuring that both nurses and parents are familiar with the process are important for successful outcomes. Preparation of environment, parent and patient are essential. Clean environment minimises risk of infection to the new-born. Preparation of parent, by completion of basic needs, washing and appropriate clothing with front-opening shirt is necessary. Being ready will help the parent to focus on baby to optimize bonding experience. Preparation of infant by assessment of vital signs and stability before transfer, change of diaper, removal of clothing, suction of ETT and placement in supine position need to be undertaken (DiMenna 2006). For transfer of infant to parent, the optimal transfer technique outlined above should be used. Consistent monitoring is required, of the baby’s vital signs and alertness for any discomfort. According to DiMenna (2007), a two-person transfer back to incubator should be done smoothly when the baby starts showing signs of unsettled activity. The infant should be re-settled in the incubator, a complete assessment done, diaper changed, ETT tube suctioned, and the infant positioned to sleep for a few hours. The mother should be asked to pump breast milk, since kangaroo care stimulates its production. The KC intervention should be recorded, with infant’s participation and tolerance. This will facilitate evaluation and follow-up by the healthcare team. Provision of support and encouragement to the parents will reassure them of its benefits for routine use in future, for as long as the infant requires the care (DiMenna 2007). Conclusion This essay has highlighted kangaroo care for the ventilated infant. A critical analysis of the literature has helped to draw useful conclusions. Rooted deeply in the strong foundations of naturalism and developmental care, kangaroo care is found to be beneficial even for the very preterm and ill neonate. This is contrary to earlier assumptions that only healthy full-term infants, or stabilised preterm infants were eligible for the intervention. Research evidence indicates that physiological stabilisation of the critically ill intubated neonate takes place faster with KC. The guidelines for stabilisation of the infant, limitations of kangaroo care, barriers to using the intervention, and a protocol for KC have been identified. It is clear that evidence-based nursing practise and continued learning in this area are required. Nurse education in kangaroo care should include its benefits for the critically ill neonate and the parent, along with knowledge and skills for undertaking KC safely and effectively. This paper has supported one’s development through providing deep insights into an area of neonatal care that was full of uncertainties and conflicting perspectives. The benefits are now clear, of using a relatively new, though natural form of intervention for the ventilated newborn infant. To optimise the benefits of kangaroo care for ventilated infants, future research should focus on increasing safe practices through the use of improved technology and methods. Word Count: 2534 words References Cattaneo, A., Davanzo, R., Worku, B., Surjono, A., Echeverria, M., et al. (1998). Kangaroo mother care for low birthweight infants: a randomized controlled trial in different settings. Acta Paediatrica, 87: 976-985. Charpak, N. & Ruiz-Pelaez, J.G. (2006). Resistance to implementing kangaroo mother care in developing countries, and proposed solutions. Acta Paediatrica, 95: 529-534. Cong, X., Ludington-Hoe, S.M., McCain, G. & Fu, P. (2009). Kangaroo care modifies preterm infant heart rate variability in response to heel stick pain: Pilot study. Early Human Development: 1-7. DiMenna, L. (2007). Considerations for implementation of a neonatal kangaroo care protocol. Neonatal Network, 25 (6): 405-413. Dodd, V. (2002). Implications of kangaroo care for growth and development in preterm infants. Journal of Obstetric, Gynecologic and Neonatal Nursing, 34 (2): 218-232. Feldman, R., Eidelman, A., Sirota, L. & Weller, A. (2002). Comparison of skin-to-skin (kangaroo) and traditional care: parenting outcomes and preterm infant development. Pediatrics, 110 (1): 16-26. Fischer, C., Sontheimer, D., Scheffer, F., Bauer, J. & Linderkamp, O. (1998). Cardiorespiratory stability of premature boys and girls during kangaroo care. Early Human Development, 52: 145-153. Gale, G., Frank, L. & Lund, C. (1993). Skin-to-skin (kangaroo) holding of the intubated premature infant. Neonatal Network, 12 (6): 49-57. Hunt, F. (2008). The importance of kangaroo care on infant oxygen saturation levels and bonding. Journal of Neonatal Nursing, 14: 47-51. Kledzik, T. (2005). Holding the very low birth weight infants: skin-to-skin techniques. Neonatal Network, 24 (1): 7-15. Ludington-Hoe, S.M., Ferreira, C., Swinth, J. & Ceccardi, J. (2003). Safe criteria and procedure for kangaroo care with intubated preterm infants. Journal of Obstetrics, Gynecologic and Neonatal Nursing, 32 (5): 579- 588. Ludington-Hoe, S.M., Ferreira, C.N. & Goldstein, M.R. (1998). Kangaroo care with a ventilated preterm infant. Acta Pediatrica, 87: 711-713. Ludington-Hoe, S. M. & Swinth, J.Y. (1996). Developmental aspects of kangaroo care. Journal of Obstetric, Gynecologic and Neonatal Nursing, 25 (8): 691-702. Ludington, S.M., Anderson, G.C., Swinth, J., Thompson, C. & Hadeed, A.J. (1994). Kangaroo care. Neonatal Network, 13 (4): 61-62. Miles, R., Cowan, F., Glover, V., Stevenson, J. & Modi, N. (2006). A controlled trial of skin-to-skin contact in extremely preterm infants. Early Human Development, 82: 447-455. Nirmala, P., Rekha, S. & Washington, M. (2006). Kangaroo mother care: effect and perception of mothers and health personnel. Journal of Neonatal Nursing, 12: 177-184. Pellicer, A., Gaya, F., Madero, R., Quero, J. & Cabanas, F. (2002). Noninvasive continuous monitoring of the effects of head position on brain hemodynamics in ventilated infants. Pediatrics, 109 (3): 434-440. Roller, C. (2005). Getting to know you: mother’s experiences of kangaroo care. Journal of Obstetric, Gynecologic and Neonatal Nursing, 34 (2): 210-217. Smith, H. (2007). Kangaroo or skin-to-skin care. Newcastle Neonatal Service Guidelines. NHS Trust. NNSKangarooMay2007.doc Smith, S.L. (2003). Heart period variability of intubated very low birth weight infants during incubator care and maternal holding. American Journal of Critical Care, 12 (1): 28-40. van Zanten, H.A., Havenaar, A.J., Stigt, H.J., Ligthart, P.A. & Walther, F.J. (2007). The kangaroo method is safe for premature infants under 30 weeks of gestation during ventilatory support. Journal of Neonatal Nursing, 13: 186-190. Wallin, L., Rudberg, A. & Gunningberg, L. (2004). Staff experiences in implementing guidelines for Kangaroo Mother Care – a qualitative study. International Journal of Nursing Studies, 42: 61-73. WHO (World Health Organisation). (2003). Essential newborn care and breastfeeding. Regional Office for Europe. Retrieved on 7th June, 2009 from: http://www.euro.who.int/document/e79227.pdf APPENDIX Safe Protocol for Kangaroo Care with Mechanically Ventilated Infants (KC-Vent) (Ludington-Hoe 2003, p.586). Kangaroo Care is skin-to-skin contact between a preterm infant and a parent, usually mother, chest-to-chest in an upright prone position. The infant is clad in a diaper and has a receiving blanket covering the infant’s back. The optimal chair for experiencing kangaroo care is a recliner. Mechanically ventilated infants are intubated or receiving nasal CPAP or oropharyngeal CPAP via a ventilator. The physician will be contacted for approval to kangaroo the infant and confirmation of infant’s hemodynamic stability. Prior to transfer 1. Record infant’s baseline ventilator parameters (SIMV/IMV, PIP, PEEP, FiO2) and hemodynamic (HR, RR, SaO2) and thermal values (axillary temperature). These measures should be carefully monitored during KC-Vent to ascertain the infant’s tolerance of this intervention. 2. With support of a second person, place the infant in supine position. Note any significant changes in the infant or mechanical ventilator requirements. 3. Auscultate the infant’s chest for quality of breath sounds, suction the endotracheal tube, and change the infant’s diaper as necessary. 4. Suction infant if necessary and drain the vent circuit of condensation. The water condensed in the ventilator tubing will be drained to decrease resistance and maintain flow (Bhutani & Abbasi, 1992). 5. Assess infant’s response to the above actions. Wait up to l5 minutes to allow for physiological adaptation to the above ministrations. Adaptation is defined as all physiological parameters returning to baseline and staying there for 3 minutes. If adaptation has not occurred in 15 minutes, the infant is probably not stable enough to receive KC-Vent on that day. 6. Place a receiving blanket, folded in fourths, underneath the infant (or in the bed but easily accessible to the mother) so mother picks up her infant by placing her hands underneath the blanket and moving infant and blanket simultaneously. 7. Position and prepare the chair to be used. Transfer From Incubator to KC-Vent 1. Have two or three staff members assist the mother in the transfer of the infant. 2. Have mother stand at the side of the incubator/warmer while one staff member gathers all the infant’s lines on one side of the infant. 3. A second staff member is responsible for transferring and securing the ventilator tubing. (A third staff member may be needed to assist the mother). 4. Disconnect the ventilator tubing from the ETT and have mother lift her infant and place prone on her chest in one movement. 5. Reconnect the ventilator tubing, and have mother or staff member quickly secure the receiving blanket across the infant’s back (if not already placed when mother picks up her infant as instructed in step 6 above). 6. Disconnect the ventilator tubing and move mother backwards to recliner/ chair, assisting her in sitting once she feels the recliner against her calf. Reconnect ventilator tubing to ETT. 7. Raise the footrest and reposition the infant, as needed, and make sure the infant is tucked in a slightly flexed or comfortable position underneath the blanket. If infant is in fully flexed position, monitor for respiratory compromise and reflux. 8. Drape the ETT circuit securely over the mother’s shoulder (be sure adequate circuit tubing length has been provided). 9. Change the setting on the incubator/warmer to air control and set it at 33.0°C for duration of KC-Vent. 10. Monitor the infant’s condition every 10 minutes during KC-Vent. Allow KC-Vent for a minimum of 1 full hour if infant’s condition remains stable. Transfer From KC-Vent Back to the Incubator 1. Have one staff member assist the mother in moving to the front edge of the chair, a second staff member handle the lines, and a third staff member disconnect the ventilator tubing. 2. Assist the mother to a standing position, reconnect the ventilator tubing, and give the infant several ventilator breaths. 3. Disconnect the ventilator tubing and replace the infant in the incubator/warming table in one movement. 4. Reconnect the ventilator tubing and make sure all ventilator tubing is stabilized and all lines are placed securely within the incubator/ warming table. 5. Document infant’s participation in and tolerance of KC-Vent. (Ludington-Hoe 2003, p.586). Read More