By Diane Schultz
“Safety should be a birthright” Clementine Wamariya
Before continuing with the posts I thought I should address a very important issue when it comes to KC
As I have said before I believe fully in the benefits of KC for any infant (premature or full term). To enable that infant and family to benefit from KC, safety must always be part of the equation.
A risk factor for Apparent Life threatening Events (ALTE) is KC that is unsupervised and without an attentive observer. Despite this risk, when comparisons are made between ALTEs with KC and ALTEs without; ALTEs without KC were higher. Another term that has been talked about since KC has been increasing in NICUs and Maternal Child areas is Sudden Unexpected Postnatal Collapse (SUPC), a rare event but can have catastrophic consequences.
Risk factors for SUPC include:
First breastfeeding attempt
Mother in episiotomy position
A primiparous mother
Parents left alone with baby during the first hours after birth
Implementations to Reduce SUPC:
A continual secure surveillance of the newborn in the first hours and days of life
Safe early skin to skin care (SSC) in the delivery room
Safe breastfeeding establishment in the first days of life
Secure positioning of the infant during sleep
SUPC of Newborn infants: A review of cases, definitions, risks and preventative measures. Herlenius E., and Kuhn P. (2013)
Our Maternal/Child department is incredibly busy as are most centres these days. Every effort must always be made to fully educate staff and the families about safety for our newborns.
Safety Education should include:
Anytime KC is happening there should be attentive and continuous observation
To facilitate respiratory expansion, infant should be elevated off of horizontal (Bohnhourst, 2010; Heinman et al, 2010)
There should be no obstruction of the infant’s nose and the head needs to be turned to one side
Neck should not be flexed or extended but in a slight “sniffing” position
Infant’s body should be positioned to maintain ventral surface to ventral surface contact
Infant should be secured with blankets, wraps and/or parent’s hands to prevent sliding (I prefer using the parent’s hands to contain the infant and then cover them both with blankets. I feel the parent has better awareness of babe’s position that way)
Our unit is made up of pods with curtains that can divide each bedside. When our parents are holding KC those curtains are to be left open so the nurse can observe. We prop our parent’s arms so they don’t get tired and tuck both in with blankets. We have also created a standard work procedure for our intubated and fragile infants so staff transfer and secure the infant the same way each time.
We also attend all high-risk deliveries. When I leave babies in kangaroo position after a delivery, I always make sure the baby’s face is turned toward the L&D nurse, not away so she can easily observe the infant even if she is tending to mom.
Everything we do in life has risks; swimming, driving a vehicle, voting, etc. To do these things there are safety measures put in place. You wouldn’t avoid driving a car because it has safety risks. You take driving lessons, pass a test, follow the rules of the road, and that way you get to enjoy the benefits of driving. I feel it is the same with KC, education and safety measures should always be in place so that infant and family can enjoy the benefits.
By Diane Schultz
I thought I would start off my series of posts with one of the most basic reasons we do Kangaroo Care.
Thermoregulation is the process of maintaining an infant’s temperature within normal range. Thermoregulation is extremely important for the newborn (term or preterm). An infant’s body surface area is 3X greater than an adult’s, causing them to potentially lose heat rapidly, up to 4X faster. When cold stressed, infants use energy and oxygen to generate warmth. Oxygen consumption can increase by as much as 10%. Thermoregulation of the infants allows them to conserve energy and build up *reserves”.
What Happens When An infant Is Placed Skin to Skin?
When the term infant is placed skin to skin at birth, the mother’s breasts immediately start to warm and conduct heat to the infant, helping to maintain normal blood sugar levels due to the infant not having to use their own brown fat to stay warm (Bergstrom et al.,2007;Bystrova et al.,2007;Ludington-Hoe et al.,2000,2006) (Chantry,2005;Christensson et al.,1992).
Kangaroo Care maintains a Neutral Thermal Environment (defined as the ideal setting in which an infant can maintain a normal body temperature while producing only the minimum amount of heat generated from basal life-sustaining metabolic processes).
In our unit, any infant that needs an incubator to maintain their temperature can only come out to be held by Kangaroo Care instead of being bundle held. To help maintain thermoregulation we make sure the infant and parent are in a draft free area, and use 2-4 layers of blankets over the infant (you can always remove a layer if needed). Infants weighing less than 1000gms should wear some type of head cap and monitor them using the incubator’s temperature probe. Remember too, we don’t want any bras or clothing between the infant and the mother, fabric will interfere with the conductance of heat from mother to infant (Ludington-Hoe et al.,2000).
One of the interesting things about KC and thermoregulation is if a mother holds twins in KC each breast works independently to warm each infant (Ludington-Hoe, et al.,2006). Triplets? Not sure, but our mothers hold their “trips” together all the time and we have had no issues.
Now, how about the father? Does he thermoregulate like the mother? With mothers you have what is called Thermal Synchrony (maternal breast temperatures changing in response to the infant’s temperature) (Ludington-Hoe, et al.,1990;1994,2000) where the fathers chests will warm up when the infant is placed in KC but will not cool down (Maastrup & Greisen, 2010). We don’t have any issues with our fathers overheating, just lots of hair to be picked off the infant after!
Skin to skin care or kangaroo care is all the rage and I am the first one to offer my support for it. Questions persist though as to whether from a physiological standpoint, babies are more stable in an isolette in a quiet environment or out in the open on their mother or father’s chests. Bornhorst et al expressed caution in their study Skin-to-skin (kangaroo) care, respiratory control, and thermoregulation. In a surprising finding, babies with an average gestational age of 29 weeks were monitored for a number of physiological parameters and found to have more frequent apnea and higher heart rates than when in an isolette. The study was small though and while there were statistical differences in these parameters they may not have had much clinical significance (1.5 to 2.8 per hour for apnea, bradycardia or desaturation events). Furthermore, does an increase in such events translate into any changes in cerebral oxygenation that might in turn have implications for later development? Tough to say based on a study of this magnitude but it certainly does raise some eyebrows.
What if we could look at cerebral oxygenation?
As you might have guessed, that is exactly what has been done by Lorenz L et al in their recent paper Cerebral oxygenation during skin-to-skin care in preterm infants not receiving respiratory support.The goal of this study was to look at 40 preterm infants without any respiratory distress and determine whether cerebral oxygenation (rStO2)was better in their isolette or in skin to skin care (SSC). They allowed each infant to serve as their own control by have three 90 minute periods each including the first thirty minutes as a washout period. Each infant started their monitoring in the isolette then went to SSC then back to the isolette. The primary outcome the power calculation was based on was the difference in rStO2 between SSC and in the isolette. Secondary measures looked at such outcomes as HR, O2 sat, active and quiet sleep percentages, bradycardic events as lastly periods of cerebral hypoxia or hyperoxia. Normal cerebral oxygenation was defined as being between 55 to 85%.
Perhaps its the start of a trend but again the results were a bit surprising showing a better rStO2 when in the isolette (−1.3 (−2.2 to −0.4)%, p<0.01). Other results are summarized in the table below:
|Mean difference in outcomes
||Difference in mean
|% time in quiet sleep
No differences were seen in bradycardic events, apnea, cerebral hypoexmia or hyperoxemia. The authors found that SSC periods in fact failed the “non-inferiority” testing indicating that from a rStO2 standpoint, babies were more stable when not doing SSC! Taking a closer look though one could argue that even if this is true does it really matter? What is the impact on a growing preterm infant if their cerebral oxygenation is 1.3 percentage points on average lower during SSC or if their HR is 5 beats per minute faster? I can’t help but think that this is an example of statistical significance without clinical significance. Nonetheless, if there isn’t a superiority of these parameters it does leave one asking “should we keep at it?”
Benefits of skin to skin care
Important outcomes such as reductions in mortality and improved breastfeeding rates cannot be ignored or the positive effects on family bonding that ensue. Some will argue though that the impacts on mortality certainly may be relevant in developing countries where resources are scarce but would we see the same benefits in developed nations. The authors did find a difference though in this study that I think benefits developing preterm infants across the board no matter which country you are in. That benefit is that of Quiet Sleep (QS). As preterm infants develop they tend to spend more time in QS compared to active sleep (AS). From Doussard- Roossevelt J, “Quiet sleep consists of periods of quiescence with regular respiration and heart rate, and synchronous EEG patterns. Active sleep consists of periods of movement with irregular respiration and heart rate, and desynchronous EEG patterns.” In the above table one sees that the percentage of time in QS was significantly increased compared to AS when in SSC. This is important as neurodevelopment is thought to advance during periods of QS as preterm infants age.
There may be little difference favouring less oxygen extraction during isolette times but maybe that isn’t such a good thing? Could it be that the small statistical difference in oxygen extraction is because the brain is more active in laying down tracks and making connections? Totally speculative on my part but all that extra quiet sleep has got to be good for something.
To answer the question of this post in the title I think the answer is a resounding yes for the more stable infant. What we don’t know at the moment except from anecdotal reports of babies doing better in SSC when really sick is whether on average critically ill babies will be better off in SSC. I suspect the answer is that some will and some won’t. While we like to keep things simple and have a one size fits all answer for most of our questions in the NICU, this one may not be so simple. For now I think we keep promoting SSC for even our sick patients but need to be honest with ourselves and when a patient just isn’t ready for the handling admit it and try again when more stable. For the more stable patient though I think giving more time for neurons to find other neurons and make new connections is a good thing to pursue!