Kangaroo Care Nursing: a Family-Centered Care for Prematurely Born Babies - Essay Example

A case study on Kangaroo Care: a family cantered care for prematurely born babies. and Kangaroo mother care (KMC) Introduction Kangaroo mother care (KMC) is an upkeep of babies born before expected delivery date (Thukral, et al., 2008). Moreover, it is care given to low weight infants and is given skin-to-skin by the mother or father of the infant (Thukral, et al., 2008). At first KMC was perceived as a substitute means to the common minimal in-hospital care usually given to infants with low birth mass (Thukral, et al., 2008). Concerns for low birth weight (usually less than 2500 g) are critical as it can affect a child’s survival and subsequent development. Statistics indicates that globally, over 25 million low birth weights are born on an annual basis with the majority of them in third world nations (Charpak & Ruiz-Pelaez, 1996). Conventional neonatal care of infants with low birth weight is quite costly and also requires highly trained personnel. The main components or aspects of KMC include the following. The Kangaroo position (skin-to-skin contact) in which the babies are kept at all times between the mother’s breasts firmly attached to the chest in an upright position. The second aspect of KMC is the Kangaroo nourishing policy i.e. frequent and special breastfeeding (Chisenga, et al., 2014). Lastly, is the discharge and follow-up policy that dictates early discharge from hospital without weight or gestational consideration (Charpak & Ruiz-Pelaez, 1996). In this light, the aim of this paper is to evaluate the kangaroo position aspect of Kangaroo mother care. This is done with special reference to heart rate; respiratory rate; temperature; apneas and bradycardias; oxygen saturation and desaturation events among low birth weight infants following the application of KMC Origins of the Kangaroo Mother Care Kangaroo mother care practice started early in the 1970s following a proposal by Klaus and colleagues for skin-to-skin contact for the initial two hours for full-term infants as therapy with the aim of facilitating maternal-infant attachment. After some time, Dr. Edgar Rey in Bogota, Colombia applied the position to preterm infants. The technique underwent refinement and was accepted for use to all preterm newborns (Moniem & Morsy, 2011). The use of the technique has since spread and is widely recognized. This is as a result of documentation of substantial evidence that link the practice with many benefits for not only preterm, but also full-term infants (Bergman & Jurisoo, 1994). The practice is however not a commonly and consistently used in the U.S. Recommendations for Kangaroo care in a clinical setting Kangaroo mother care has both physiological and clinical benefits to the infants. In the former, Kirsten, Bergman and Hann (2001) observe that heart and respiratory rates, sleep patterns, oxygen consumption of preterm infants under the KMC practice are better. This is when they are compared to those seen in infants separated from their mothers. The latter benefits hinge on breastfeeding; evidence suggests that KMC ensures breastfeeding encouragement. While literature cites numerous benefits of breastfeeding for preterm babies, it is often the case that preterm babies do not get adequate breastfeeding. Studies on KMC indicate that mothers who adopt skin-to-skin contact with their preterm infants often have higher milk production compared to those who do not do the same (Anderson, 1991). Other benefits of KMC include the following. On the part of preterm infants, KMC enhances physiologic stability and improves weight gain. Moreover, it improves the brain, cognitive and psychomotor development. In addition, it provides a better regulation of body temperature compared to that in incubators (Blencowe & Molyneux, 2005). On the part of the families for preterm infants, the technique enhances maternal and paternal attachment. Therefore, it enhances sensitivity and responsiveness on the part of the infant. Moreover, it is responsible for raising confidence and competence is provision of infant care; it creates more nurturing interactions and; it also facilitates the transition to the home environment (Blencowe & Molyneux, 2005). Clinical Evaluation of an Infant and Family Nurses are usually concerned about the infant’s response to Kangaroo mother care. This is dictated by the vital signs in addition to physiologic functions, for example, weight gain and immunologic, metabolic and hormonal effects. The subsequent section will give clinical scenarios that will reflect the application and the significance of KMC in a clinical setting. Clinical condition 1: Heart Rate Baby has the 25 weeks gestational age (GA) and 27 weeks postmenstrual age (PMA) in an incubator on room air (21% oxygen). Heart rate (HR) is fluctuate between 130 and 170 beats per minute (BPM) (Susan, 2013). Suggested current practice: The mother should hold the infant skin-to-skin simply because this will bring more stability to the heart rate than when the infant is left in the incubator (Susan, 2013). Evidence to Support current practice and management of care Kangaroo mother care ensures better heart rate stability of an infant than when the infant is placed in an incubator or even when held swaddled. According to VanRooyen, Pullen, Pattinson and Delport (2002), the HR of an infant should stay within clinically acceptable ranges. This is largely because of the fact that preterm infant HR in Kangaroo mother care is similar to incubator values. However, in the event that the heart rate changes, the changes are not significant and as such will remain within the acceptable range (VanRooyen et al, 2002). It is been shown that even twins or triplets tend to have a significantly higher HR stability when under the kangaroo mother care as compared to when placed in incubators. In addition, KMC ensures cardiorespiratory stability especially in the case of inter-hospital ambulance transport. According to the Transport Risk Index of Physiologic Stability (TRIPS) measure, the core determinant of an infection severity include fever, BP and respiration conditions of the infant (Ludington-Hoe & Morgan, 2013). Kangaroo mother care, however, can address these predictors effectively; consequently, this ability makes KMC a better transport compared to transport in an incubator (Sontheimer et al., 1995). Clinical condition 2: Respiratory Rate Baby has the following: 10 days old; 31 weeks GA; 32 3/7 weeks PMA; in an incubator on room air; on caffeine; gains 20 grams per day (Susan, 2013). Essential signs: 2-3 apneas a day; HR=136; pulse oximetry=99 percent; Respiratory Rate=42; temperature= 36.80C (Susan, 2013). Other information: The baby is held under KMC for significant periods every day. The infant breaths without difficulties but retains its pink color. In addition, the baby sleeps quietly. After an hour of the initial recording, the second recording shows HR increase to 154; Pulse oximetry increases to 100 percent; temperature increases to 37.20C; RR drops to 24 (Susan, 2013). Suggested current practice: Do not remove the infant from Kangaroo mother care as breathing is not affected. Evidence to Support current practice and management of care The infant’s RR of 24 is obviously low and outside the normal range; consequently, the infant suffers a condition called hypopnea, and this requires investigation. The lesser RR is, in many cases, indicate a standard reaction of the brain stem to fundamental oxytocin effects that occur in the medulla oblongata (Ludington-Hoe & Morgan, 2013). Since it is established that the infant has no respiratory distress, it could be necessary to have the baby’s cerebral oxygenation data. According to Kirsten, Bergman, and Hann (2001), would range between 65 and 80 percent under kangaroo mother care, and this is considered normal. Usually in the practice of kangaroo mother care, the c-afferent nerves of the mother’s and infant’s chest planes react to the pleasing touch of KMC (Verma & Verma, 2014). In the process, the nerves send a pleasing message to the brain that, in turn, triggers the release of oxytocin. The hormone then travels along the neurons to other parts of the brain. During its movement, the first target oxytocin reaches are the brain stem. Here it immediately calms and brings stabilization to the cardiorespiratory variables following the brain stem’s shift from sympathetic to parasympathetic control that occurs during Kangaroo mother care (Anderson, 1991). Sleeping is an indication of regular breathing sleep and is a characteristic of kangaroo mother care practice. Quiet sleep is, however, not a characteristic of sleep in an incubator (Scher, et al., 2014). Kirsten, Bergman, and Hann (2001) say that the quiet sleep more often accompanies a parasympathetic-induced low RR, and this can decrease even more. He adds that in the course of KMC, a baby’s RR may go up slightly or sometimes decrease by 3-6 minutes per minute. According to Dood (2005), a decrease in RR is a common occurrence in normal sleeping patterns and is usually because the infant sleeps while being in a head-up tilted position or a prone position. This mostly coincides well in the second or third hour of kangaroo mother care, a time when there is an alteration of the respiratory drive. This is due to the stimulation of the sensitive adenosinergic prolongation (Dood, 2005). In many cases, respiratory rate during the Kangaroo mother care is usually the same as that in the incubator and even in ventilated infants. It has also been established that there occurs a significantly high stability soon after the onset of Kangaroo mother care. Although there are some apparent variations, RR responses do not exceed the clinically acceptable ranges. Therefore, it have not triggered any physiologic compromise; consequently, kangaroo mother care is safe in regard to its impact on respirations (Susan, 2013). Clinical condition 3: Apneas and Bradycardias Baby has the following: 2 weeks old; 29 weeks GA; on a nasal cannula one liter per minute; on caffeine (Susan, 2013). Critical signs: An average of 3-4 apneas per day, with or without bradycardias. Suggested current practice: Holding the infant in KMC will help in reducing the episodes of apnea and bradycardias (A/B) (Susan, 2013). Evidence to Support current practice and management of care There is a common misconception that holding infants in kangaroo mother care will increase A/Bs; however, studies suggest otherwise. According to Blencowe and Molyneux, (2005), apnea and bradycardias events do not occur during kangaroo mother care. In the event that they occur, they decrease by up to 75 percent compared to that in the incubator. The same studies are also true when it comes to even in extremely low birth weight infants at 25 weeks post-conceptual age (Susan, 2013). Kangaroo mother care practice has been shown to significantly lower transitions while sleeping and is also key in reducing arousal from sleep. Kangaroo mother care is known to maintain long periods of sleep. As a result, it lowers the number of an infant’s sleep transitions. Apneas condition often occurs in the event that an infant transitions between active sleep and quiet sleep. When in the incubator, it is always the vigorous sleep that preponderates (Ludington-Hoe & Morgan, 2013). During this sleep mode, preterm infants experience uneven breathing occasioned with unbalanced baseline oxygen saturation (Ludington-Hoe & Morgan, 2013). As a result, apnea tends to occur more frequently in active sleep as compared to the rate of occurrence in quiet sleep (Bergman & Jurisoo, 1994). According to Bergman and Jurisoo (1994), KMC practice is critical in reducing arousals from sleep. Usually, arousals from active sleep are risk factors to predisposing infants to apnea with oxygen desaturations largely because motor activities are often accompanied by laryngeal obstruction that is responsible for causing obstructive apnea. When a preterm baby is held in a standing and predisposed positioning during the Kangaroo mother care, the A/Bs reduces significantly (Jefferies, 2012). It has also been shown that infants that are elevated from 15 to 30 degrees in the KMC position are less likely to experience A/Bs. This is when they are compared to their horizontally held counterparts (Bergman & Jurisoo, 1994). Also, prone positioning facilitates the functioning of the lungs that consequently optimizer are breathing. Clinical Condition 4: Temperature Baby has the following: 3 weeks old, 26 weeks GA, 29 weeks PMA and are on cannula at 1LPM with 25% FiO2. All this is when they are in an incubator within her neutral thermal environment (Susan, 2013). Vital sign: Temperature is within normal limits Additional information: The mother has not had the opportunity to hold the baby in KMC for four days. Mother fears that the baby is too small and would get cold if she exercised KMC on her baby (Susan, 2013). Suggested current practice: Perform Kangaroo mother care on the infant as opposed to letting her in an incubator. Evidence to Support current practice and management of care It is important to ensure that preterm infants are supplied with enough heat and moisture as this helps in maintaining their temperature. Exposure of the infant’s chest and back can lead to evaporative and convective heat losses especially during transfer and throughout kangaroo mother care. As such, VanRooyen et al. (2002) suggests that preterm infants should remain covered at all times be it during transfer or in KMC largely because an infant’s stress increases significantly when not covered. Immediately kangaroo mother care commences VanRooyen et al. (2002) says heat transfer from the mother to the infant begins, and this is usually enough to offer compensation for the one lost in both evaporative and convective losses. It has been shown that during Kangaroo mother care practice, an extremely low birth weight preterm infants tend to gain heat faster compared to when they are in an incubator. During kangaroo mother care practice, Charpak and Ruiz-Pelaez (1996) say the preterm infant’s body temperature is easily maintained. Although there could be heat loss in the course of skin-to-skin contact with the mother, the amount lost is usually small and can only cause little or no effect on the infant’s fluid balance. Since most of the heat is usually lost through the unprotected heads. Therefore, it is recommended that preterm infants weighing less than 1,000 grams and are less than 28 weeks to wear head caps (Susan 2013). The amount of humidity that is provided by KMC is, however, sufficient for the preterm infant. Clinical condition 5: Oxygen Saturation and desaturation events Baby has the following: 4 weeks old; 26 weeks GA; 30 weeks PMA; appears to be sleeping quietly (Susan 2013). Critical signs: Temperature= 36.90C; HR=138; RR=52; Oxygen saturation is fluctuating between 88 and 96 percent without color change (Susan 2013). Suggested current practice: Continue holding the infant in KMC as failure to do so may bring harm to long-term neurodevelopment. Evidence to Support current practice and management of care Studies variously show that although in some instances there could be a decline of oxygen saturation of up to 0.6 percent during KMC and subsequent transfer to KMC, recovery occurs quickly within a time span of 3 minutes. As such, a reduction of desaturation events may lead to stabilization of oxygen saturation (Susan 2013). Criticism of the Kangaroo position component of KMC While the kangaroo position component is supported by literature as an effective way in kangaroo mother care, there are arguments advanced against the same. The following are some of the criticism of the kangaroo aspect of the KMC practice (Venancio & Almeida, 2004). Some critics argue that direct skin-to-skin contact as presented by KMC is “unusual” or even “improper.” This argument stems from cultural reactions of professionals, mothers and their families and the influence of technology that, in many cases, influences their views and habits with regards to baby caring. Some mothers are also not comfortable with carrying an infant in skin-to-skin contact continuously. In some cultures, it remains quite unusual to position the baby on the chest and, as such, people tend to shun away the kangaroo position (Charpak & Ruiz-Pelaez, 2006). Another argument is as a result of the concerns of the mother’s privacy and diffidence (Charpak & Ruiz-Pelaez, n.d.). It is often the case that mothers and some healthcare workers feel quite uncomfortable when mothers have to be exposed to strangers in the process of being shown how the kangaroo position works. In some cultures, it is prohibited to expose once naked skin; consequently, the kangaroo position is considered as inappropriate as it leads to exposure of the mother’s skin (Charpak & Ruiz-Pelaez, 2006). Another argument against the kangaroo position concerns the newborn cap (bonnet) and socks. Many people especially the professionals detest the compulsory wearing of caps and socks by the young ones. There is a common argument that caps and socks should not be worn especially in warm climates as the temperatures are considered high enough to deter heat loss when the baby is held in Kangaroo position. As such, the use of caps and socks in warm climates is often considered an exaggeration, demeaning to the baby and inappropriate (Charpak & Ruiz-Pelaez, 2006). Some mothers also object to maintain the Kangaroo position in 24 hours a day. While mothers are determined to do everything within their means for the well-being of the infants, some find the kangaroo position too demanding. In addition, the environment in which the mothers operate can be a hindering factor to the success of the kangaroo position. In most neonatal units across the world, there is lack of enough space required for offering the expected standards of comfort specified in the kangaroo mother care technique (Charpak & Ruiz-Pelaez, 2006). In most developing countries, the KMC wards are particularly not well equipped with the necessary equipments that provide mothers the comfort of doing KMC 24 hours a day. Some cultural expectations also hinder successful application of the Kangaroo position (Morrison, 2004). In many cultures and especially in developing countries, women are the ones who perform a lot of work at home. In addition to tending to their newborn infants and siblings, women are also expected to take care of the extended families especially mothers in law. In many cases, the mother in law dictates what should be done what should not and the daughter is not expected to obey everything. In the event that these family stakeholders do not recognize KMC, it becomes difficult for a mother to implement the Kangaroo position (Charpak & Ruiz-Pelaez, 2006). In some cultures, the mother will work while holding the baby at the back; as such, carrying an infant in front while working highly inconveniences the mother from conducting her daily chores. Conclusion In conclusion, Kangaroo mother care is an important technique that is used to support the children born either extremely or low birth weights (usually less than 2500g). It is less costly compared to the conventional neonatal care such as the use of incubators (Vahidi, et al., 2014). The practice has many benefits both to the preterm infants and to the families of the preterm infant (The Joanna Briggs Institute, 2010). KMC has three main components which include kangaroo position, kangaroo feeding policy and kangaroo discharge and follow-up policies (Charpak & Ruiz-Peláez, 2006). The practice has been shown to offer a remedy to various clinical conditions that fall under the Kangaroo position component including heart rate, respiratory rate, and temperature among others (The Joanna Briggs Institute, 2010). However, there has been criticism to the kangaroo position with arguments such as the failure to observe cultural norms. References Anderson G.C., 1991. ‘Current knowledge about skin-to-skin (kangaroo) care for preterm infants. Journal of Perinatology, 11:216-226. Bergman N.J, and Jurisoo L.A., 1994. ‘The kangaroo-method for treating low birth weight babies in a developing country. Trop Doct, 24(2):57-60 Blencowe H. and Molyneux E.M., 2005. ‘Setting up kangaroo mother care at Queen Elizabeth Central Hospital, Blantyre - a practical approach.’ Malawi Medical Journal 17(2):39–42. Charpak N, and Ruiz-Pelaez J.G., 2006. ‘Resistance to implementing Kangaroo mother care in developing countries, and proposed solutions’ Acta Paediatr, 95(5): 529-34 Charpak N, and Ruiz-Pelaez J.G., 1996. ‘Current knowledge of kangaroo mother intervention.’ Current Opinion in Pediatrics, 8:108-112. Charpak, N. & Ruiz-Peláez, J. G., 2006. Resistance to implementing Kangaroo Mother Care in developing countries, and proposed solutions.. Acta Paediatr, 95(5), pp. 529-534. Charpak, N. & Ruiz-Pelaez, J. G., n.d. Sources of resistance to Kangaroo Mother Care (KMC) implementation in developing countries and proposed solutions. [Online] Available at: http://kangaroo.javeriana.edu.co/encuentros/6encuentro/Sourcesof%20resistance%20to%20Kangaroo%20Mother%20Care.pdf [Accessed 16 December 2014]. Chisenga, J. Z., Chalanda, M. & Ngwale, M., 2014. Kangaroo Mother Care: A review of mothers׳ experiences at Bwaila hospital and Zomba Central hospital (Malawi). [Online] Available at: http://www.midwiferyjournal.com/article/S0266-6138%2814%2900118-1/fulltext [Accessed 16 December 2014]. Dood V.L., 2005. ‘Implications of kangaroo care for growth and development in preterm infants. J Obstet Gynecol Neonatal Nurs, 34(1):218-32.  Jefferies, A. L., 2012. Kangaroo care for the preterm infant and family. [Online] Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3287094/pdf/pch17141.pdf [Accessed 16 December 2014]. Kirsten G, Bergman N.J, and Hann F.M., 2001. Kangaroo Mother Care in the nursery. Pediatric Clinics of North America, 48 (2):443–452. Ludington-Hoe, S. M. & Morgan, K. L., 2013. Kangaroo care in the NICU, part 1:Understanding the impact of kangaroo care on neonatal vital signs. [Online] Available at: http://www.marchofdimes.org/nursing/modnemedia/othermedia/articles/art01_kangaroo_care_pt1_text.pdf [Accessed 16 December 2014]. Moniem, I. I. A. E. & Morsy, M. A., 2011. The Effectiveness of Kangaroo Technique on Preterm Infant’s Weight Gain. Journal of American Science, 7(1), pp. 697-702. Morrison, B. B., 2004. Preterm birth. Clin Evid, Volume 11, pp. 1903-1922. Scher, M. S. et al., 2014. Neurophysiologic Assessment of Brain Maturation: Preliminary results of a six-week trial of skin contact preterm. [Online] Available at: https://www.nsf.no/Content/113898/PediatrRes2006%20NeurophysAssessBrainMaturation.doc [Accessed 16 December 2014]. Sontheimer D, et al., 1995. ‘Pitfalls in respiratory monitoring of premature infants during kangaroo care.’ Archives of Disease in Childhood, 72 (1): 115-117. Susan M.L., 2013. ‘Kangaroo care in the NICU, part 1: Understanding the impact of Kangaroo care on neonatal vital signs’ [Online]. Available at http://www.marchofdimes.org/nursing/index.bm2?cid=00000003&spid=ne_s1_1&tpid=ne_art01_kangaroo_care_pt1_home [Accessed 15th December 2014] The Joanna Briggs Institute , 2010. Positioning of preterm infants for optimal physiological development. [Online] Available at: http://connect.jbiconnectplus.org/ViewSourceFile.aspx?0=5391 [Accessed 16 December 2014]. Thukral, A. et al., 2008. Kangaroo Mother Care an alternative to conventional care. [Online] Available at: http://newbornwhocc.org/pdf/Kangaroo_Mother_%20Care050508.pdf [Accessed 16 December 2014]. Vahidi, R. G. et al., 2014. Cost and effectiveness analysis of Kangaroo mother care and conventional care method in low birth weight neonates in Tabriz 2010-2011. Journal of Clinical Neonatology, 3(3), pp. 148-152. Van Rooyen E, Pullen A.E, Pattinson R.C, and Delport S.D., 2002. ‘The value of the kangaroo mother care unit at Kalafong Hospital. The Medical Journal; 27(3): 6–10. Venancio, S. I. & Almeida, H. d., 2004. Kangaroo Mother Care: scientific evidences and impact on breastfeeding. Jornal de Pediatria, November, 80(5), pp. 173-180. Verma, P. & Verma, V., 2014. Effect of Kangaroo Mother Care on Heart rate, Respiratory rate and Temperature in Low Birth Weight Babies. International Journal of Medical Research and Review, 2(2), pp. 81-86. Read More