Isn't it time for a little Kangaroo in your NICU?

Isn't it time for a little Kangaroo in your NICU?

Aside from me donning the costume in the above picture for the Kangaroo Challenge 2017 I learned something new today.  Before I get into what I learned, let me say that I had the opportunity to put so many smiles on parents faces by walking around in this full body costume that I am grateful to Diane for finding this costume and Sue (you both know who you are) for purchasing it.  Handing out cookies to the parents and children at the bedside and seeing them smile while knowing that they were under significant stress gave me the opportunity to interact with parents in a very different way than I am accustomed to as a Neonatologist so I am so thankful to have had that experience and yes if called upon I will do it again!

We even made the local news! CTV newscast

I posted the above picture on my Facebook page and to my surprise many of the comments led me to believe that Kangaroo Care is still something that needs a little nudging to get the word out about.  I found this actually quite surprising given how immersed we are in Winnipeg with this strategy.  When I think about new interventions in Neonatology it is synonymous in virtually all cases with an influx of dollars to achieve usher in the new program.  Here is a program that is virtually free but only requires a commitment from families to spend the time at the bedside with their baby in the NICU.

I have been asked by many of my nursing colleagues to write something about Kangaroo care on this site and so here it is…

What is it?

You have likely heard of Kangaroo Care and you may have even seen some children receiving it in your hospital.  Why is this so important?

Kangaroo Care (KC) or Skin to Skin Care (STS) is an ideal method of involving parents in the care of their premature infant.  It fosters bonding between parents and their hospitalized infant, encourages the family to be with their child and thereby exposes them to other elements of neonatal care that they can take part in.  While we know that many units are practising Kangaroo Care there is a big difference between having KC in your unit and doing everything you can to maximize the opportunity that your families have to participate.

There is much more to KC than simply holding a baby against your chest.  For a demonstration of KC please watch the accompanying video and show it to any one in your units that may need a visual demonstration.  This excellent video is from Nationwide Children’s Hospital and walks you through all of the important steps to get it right and maximize benefit.

Kangaroo Care Video

Before you reach the conclusion that KC only serves to enhance the parental experience it does so much more than that.  The practice began in Bogota Columbia in 1979 in order to deal with a shortage of incubators and associated rampant hospital infections.  The results of their intervention were dramatic and lead to the spread of this strategy worldwide.  The person credited with helping to spread the word and establish KC as a standard of care in many NICUs is Nils Bergman and his story and commentary can be found here http://bit.ly/1cqIXlm

The effects of KC are dramatic and effective to reduce many important morbidities and conclusively has led to a reduction in death arguably the most important outcome.  An analysis of effect has been the subject of several Cochrane Collaboration reviews with the most recent one being found here.

To summarize though, the use of KC or STS care has resulted in the following overall benefits to premature infants at discharge or 40 – 41 weeks’ postmenstrual age:

Reduction in

mortality  (typical RR 0.68, 95% CI 0.48 to 0.96)

nosocomial infection/sepsis  (typical RR 0.57, 95% CI 0.40 to 0.80)

hypothermia (typical RR 0.23, 95% CI 0.10 to 0.55)

Increase in

KMC was found to increase some measures of infant growth, breastfeeding, and mother-infant attachment

To put this in perspective, medicine is littered with great medications that never achieved such impact as simply putting your child against your chest.  This is another shining example of doing more with less.  This is not to say that modern medicine and technology does not have its place in the NICU but KC is simply too powerful a strategy not to use and promote routinely in the NICU.

Please join me in championing this wonderful technique and make a difference to all of our babies!

A sample of our parent letter to promote KC is found in the link below.

Parent letter II

Kangaroo Care Counterpoint: What About the Term Infant?

Kangaroo Care Counterpoint: What About the Term Infant?

After releasing yesterdays post Skin to Skin Fad Blamed For Death of Babies I entered into a very interesting discussion on Twitter with Clay Jones of Science Based Medicine.org.  Emily Hahn (@TexasKidDoc) was also instrumental for setting up the discussion so I thank her for connecting Clay and I once again.  At issue was whether the “Fad” of Skin to Skin Care was indeed to blame for the observations in Australia.

Clay in fact his written on this topic as well but from KC in the term infant perspective and I would encourage you to read his piece as a “counterpoint” below.

Kangaroo Mother Care, Skin-To-Skin Contact, and the Risk of Sudden Unexpected Postnatal Collapse

My gut reaction given that I am immersed in a culture of Kangaroo Care was to defend the usage but he raises a very important point that I think is worth addressing.

No one is disputing the benefits of Kangaroo Care for preterm infants which I won’t go into here as I have done so yesterday.  The question being posed is whether such benefits extend to the term infant and whether it can be done safely.  The preterm infant experiencing KC in a prone position is of course monitored with a nurse close by.  The patient in the room alone with a mother who has recently delivered is not necessarily supervised to the same degree.  Also if the baby is unmonitored then is it safe?

Still A Big Supporter of Kangaroo Care

I am not changing my tune so to speak as there are many benefits in terms of breastfeeding, maternal-infant bonding, thermoregulation etc that will be achieved through KC.  What I do mean to at least raise some awareness of though is the concern that without a proper preventative strategy in the term infant population falls and or asphyxiation from a mother who falls asleep with the infant in between her breasts is possible.  Readers of this blog on Facebook yesterday acknowledged they have seen such events happen and I can say myself that I have as well.

Let’s practice KC and endorse it but in the end let’s all be safe.  In the end the question then is was the title of the Yahoo post truly that inflammatory?!  What it inferred I think was but as it pertained to the hospital experience perhaps there was something there.

What do you think?

Addendum: From Keith Barrington

There are now several publications about this happening, (including our case report, Schrewe B, et al. Life-threatening event during skin-to-skin contact in the delivery room. BMJ Case Rep. 2010;2010(dec21 1):bcr1120103475-bcr.) At the time we wrote our report we found 59 cases in the literature, and 56 of them had been in skin to skin with the mother.
A French group published a number of risk factors for sudden unexpected life-threatening events after an uneventful delivery at term, which included skin to skin position and maternal obesity.
It is clear that this is very rare ( German group calculated the incidence as 2.6 per 100,000 deliveries), but it is potentially devastating, mortality is high, and neurologic compromise also.
Our take on this was that given the benefit in terms of breast feeding initiation etc, and the rarity of problems, that we should not discourage the practice, but never leave a new mother alone with the baby in skin to skin, someone else should be in the room to keep an unobtrusive eye on the baby, it could be the father (if he had some idea what to watch for) or a health care worker. As the mechanism is probably simple suffocation, a pulse oximeter could be a potential way of surveying for teh occurrence, if something more natural was not available.

 

Skin-to-skin fad blamed for deaths of babies!

Skin-to-skin fad blamed for deaths of babies!

As the practice seems to be winning the world over you can imagine that a headline entitled,

‘Skin-to-skin’ fad blamed for deaths of babies

would get some attention.  This article was sent to me by a colleague after being published last month on Yahoo news service.  The claim is based on the experience of a hospital in Perth that has seen some cases of neonatal suffocation after mothers who were performing skin to skin care fell asleep and rolled onto their newborn.  This “fad” they say is attributable as the cause of death.  Before looking into whether there is any basis for such a claim it may be worth exploring whether Kangaroo Care (KC) otherwise known as Skin to Skin (STS) care is effective.  The irony is not lost on me either that safety of Kangaroo Care is being challenged in Australia…

Is KC Effective in the NICU?

KC or is an ideal method of involving parents in the care of their premature infant.  It fosters bonding between parents and their hospitalized infant, encourages the family to be with their child and thereby exposes them to other elements of neonatal care that they can take part in.

Before you reach the conclusion that KC only serves to enhance the parental experience it does so much more than that.  The practice began in Bogota Columbia in 1979 in order to deal with a shortage of incubators and associated rampant hospital infections.  The results of their intervention were dramatic and lead to the spread of this strategy worldwide.  The person credited with helping to spread the word and establish KC as a standard of care in many NICUs is Nils Bergman and his story and commentary can be found here.

The effects of KC are dramatic and effective to reduce many important morbidities and conclusively has led to a reduction in death arguably the most important outcome.  An analysis of effect has been the subject of several Cochrane Collaboration reviews with the most recent one being found here.

To summarize though, the use of KC or STS care has resulted in the following overall benefits to premature infants at discharge or 40 – 41 weeks’ postmenstrual age:

Reduction in

mortality  (typical RR 0.68, 95% CI 0.48 to 0.96)

nosocomial infection/sepsis  (typical RR 0.57, 95% CI 0.40 to 0.80)

hypothermia (typical RR 0.23, 95% CI 0.10 to 0.55)

Increase in

KMC was found to increase some measures of infant growth, breastfeeding, and mother-infant attachment

To put this in perspective, medicine is littered with great medications that never achieved such impact as simply putting your child against your chest.  This is another shining example of doing more with less.  This is not to say that modern medicine and technology does not have its place in the NICU but KC is simply too powerful a strategy not to use and promote routinely in the NICU.

What About Term Infants?

Much has been written on the subject.  A Pilot study in 2007 by Walters et al found benefits in newborn temperature, glycemic control and initiation of breastfeeding.  Perhaps the strongest evidence for benefit comes from a cochrane review of the subject last updated in 2012.

Early skin-to-skin contact for mothers and their healthy newborn infants.

This analysis included 34 RCTs with 2177 participants (mother-infant dyads). Breastfeeding at one to four months postbirth (13 trials; 702 participants) (risk ratio (RR) 1.27, 95% confidence interval (CI) 1.06 to 1.53, and SSC increased breastfeeding duration (seven trials; 324 participants) (mean difference (MD) 42.55 days, 95% CI -1.69 to 86.79) but the results did not quite reach statistical significance (P = 0.06). Late preterm infants had better cardio-respiratory stability with early SSC (one trial; 31 participants) (MD 2.88, 95% CI 0.53 to 5.23). Blood glucose 75 to 90 minutes following the birth was significantly higher in SSC infants (two trials, 94 infants) (MD 10.56 mg/dL, 95% CI 8.40 to 12.72).

Taken together there are benefits although the impact on breastfeeding rates in term infants show a strong trend while not reaching statistical significance.  Importantly though in this large sample we don’t see any increase in mortality nor to my knowledge has there ever been a study to show an increase.

How do we deal with this claim from Australia then?

I think the problem with this claim is that KC is being blamed after a “root cause analysis” has come to the wrong conclusion.  The problem is not KC but rather a lack of a “falls prevention” strategy on the postpartum units.  Mothers after delivery are exhausted and may be on pain medication so as the saying goes “there is a time and a place”.  As our hospital prepares for accreditation again, safety to prevent falls (including babies falling out of mom’s arms or in a similar vein mothers falling onto babies) is something that every hospital needs.  Whether a mother is practicing KC, breastfeeding or simply holding her baby if a mother falls asleep while doing so there is a risk to the infant.  If the hospital in this case has seen an increase in such cases of newborn deaths while performing KC then it is likely the hospitals lack of attention to minimizing risk in the postpartum period that is to blame and not KC itself.  Certainly the evidence from rigorously done trials would not support this claim.

This hospital would do well to have a comprehensive plan to educate parents about the risks of fatigue, ensure bassinets are next to every bed to provide mothers with an easy transfer if they are tired.  Certainly during the immediate period after delivery mothers, partners of mothers who have just delivered should be encouraged to be with them or advise the mothers if they are tired to put the baby down and rest.  A little education could go a long way!

I think it is a cheap out to blame KC for such problems as it turns our attention away from the real issue and that is a lack of policy and education.  So in the end I would like to state emphatically that…

No I don’t believe the “skin-to-skin fad” is to blame for an increase in deaths!

 

 

 

What Are You Waiting For? Take the Kangaroo Care Challenge!

What Are You Waiting For? Take the Kangaroo Care Challenge!

 

It’s the 5th International Kangaroo Care Day!

We took the challenge this year again and I am happy to announce achieved even greater success than last time around!  Since the last time we have purchased special clothing to facilitate the practice and with this new initiative perhaps it helped us reach new highs!  Here are the results paraphrased from one of our very own!

At St. Boniface Hospital

“663 hours and 29 minutes.  This means 2 hours and 4 minutes per patient per day.

The really great part of this is the involvement we had from L&D and LDRP.  Both units kept log sheets and informed patients and visitors about the importance of Skin to Skin.

L&D logged 65 hours and 27 minutes for 58 patients which equals more than an hour per patient, their patients don’t stay as long.

LDRP logged a total of  268 hours and 47 minutes for 34 patients which is more than 8 hours of skin to skin per patient and baby. LDRP had some parents who did more than 15 hours during their hospital stay, one family logged 34 hours!

At HSC

321 hours of KC  in the 3 Neonatal Areas combined!

 .5 hours per patient per day eligible for KC!    (excludes those too sick)

How Does This Compare to Last Year (For St.B)?

Sunnybrook NICU in Toronto put out a challenge to promote Kangaroo Care for a two-week period to  in the NICU.  We took the challenge at St. Boniface Hospital and here are the results…IMG_0160

Our dates were from April 13-27.

We totaled 647 hours and 10 minutes, equals 27 days worth of skin to skin.

Total of 36 babies in the unit, another 14 infants that were held KC while in a C-section or being monitored by our Observation staff (these babies had TTN and were being transitioned KC in L&D and LDRP.

We had 9 long term micro premies that were in the unit at the time of the challenge, they averaged 33-69 hours during the two week period.

Not bad at all I say based on the number of babies we had!  This represents an average of 18 hours of KC per baby over that time!

You have likely heard of Kangaroo Care and you may have even seen some children receiving it in your hospital.  Why is this so important?

Kangaroo Care (KC) or Skin to Skin Care (STS) is an ideal method of involving parents in the care of their premature infant.  It fosters bonding between parents and their hospitalized infant, encourages the family to be with their child and thereby exposes them to other elements of neonatal care that they can take part in.  While we know that many units are practising Kangaroo Care there is a big difference between having KC in your unit and doing everything you can to maximize the opportunity that your families have to participate.

There is much more to KC than simply holding a baby against your chest.  For a demonstration of KC please watch the accompanying video and show it to any one in your units that may need a visual demonstration.  This excellent video is from Nationwide Children’s Hospital and walks you through all of the important steps to get it right and maximize benefit.

https://www.youtube.com/watch?v=_MateX87u9k

Before you reach the conclusion that KC only serves to enhance the parental experience it does so much more than that.  The practice began in Bogota Columbia in 1979 in order to deal with a shortage of incubators and associated rampant hospital infections.  The results of their intervention were dramatic and lead to the spread of this strategy worldwide.  The person credited with helping to spread the word and establish KC as a standard of care in many NICUs is Nils Bergman and his story and commentary can be found here http://bit.ly/1cqIXlm

The effects of KC are dramatic and effective to reduce many important morbidities and conclusively has led to a reduction in death arguably the most important outcome.  An analysis of effect has been the subject of several Cochrane Collaboration reviews with the most recent one being found here.

To summarize though, the use of KC or STS care has resulted in the following overall benefits to premature infants at discharge or 40 – 41 weeks’ postmenstrual age:

Reduction in

mortality  (typical RR 0.68, 95% CI 0.48 to 0.96)

nosocomial infection/sepsis  (typical RR 0.57, 95% CI 0.40 to 0.80)

hypothermia (typical RR 0.23, 95% CI 0.10 to 0.55)

Increase in

KMC was found to increase some measures of infant growth, breastfeeding, and mother-infant attachment

To put this in perspective, medicine is littered with great medications that never achieved such impact as simply putting your child against your chest.  This is another shining example of doing more with less.  This is not to say that modern medicine and technology does not have its place in the NICU but KC is simply too powerful a strategy not to use and promote routinely in the NICU.

Please join me in championing this wonderful technique and make a difference to all of our babies!

A sample of our parent letter to promote KC is found in the link below.

Parent letter II