Skin to skin care (STS) or kangaroo care (KC) has quickly become one of the hot topics in neonatal care these days. The benefits have been spoken of before and as we learn more about the benefits it isn’t surprising to see studies emerge looking at novel groups who might benefit from the same. Dr. Kribs and her team in Cologne, Germany put themselves on the map with studies demonstrating the potential use of and benefits from LISA techniques for surfactant administration. The same unit is at it again but this time asking a different but very important series of questions.
Combatting the challenges the mother-infant dyad face after delivery
Traditionally, our smallest infants are resuscitated and shown to the parents before being taken to the NICU for ongoing care in an isolette. Dr. Kribs and her group wondered about the effect that separation could have on the mother-child interaction (MCI). The groups were comprised of infants born between 25 +0 – 32+ 0 weeks gestation. They postulated in a randomized controlled trial that after stabilization with or without surfactant that there would be a benefit to having these dyads spend 45 minutes in STS vs the traditional 5 minute visual contact with touching allowed of the face but not anywhere on the body since the infant was wrapped in protective thermal wrap. To test the difference in MCI at 6 months the authors shot a 4 minute video of the mother and child together and using blinded reviewers assessed the interaction between the dyad. The interaction involved the mother changing the diaper and playing with their children.
From the study; “Maternal and infant behavior was assessed using the Mannheim Rating System, a well validated standardized observation instrument(16). Videos were analyzed by two trained raters blind to randomization.”
Self reports of other important outcomes such as depression, bonding and more objective study of salivary cortisol were also performed. Salivary cortisol elevations were apparently blunted in another study at 4 months of age in infants who experienced more pain and stress in the NICU.
Like many studies looking at a brief intervention in the life of a child this one had some findings that are worth discussing.
Overall, the rate of positive MCI was higher in the group randomized to STS (86 (±26) vs 71 (±32), p=0.041, OR 0.982, CI [0.7-1]). This difference was due to three particular differences in the MCI studies.
Maternal motoric response, infant vocal response and infant motoric response. What this meant specifically is that infant and maternal physical interactions were deemed positive in terms of facial expressions, physical movement or vocalizations more when delivery room STS was performed than when not. Infants were also more vocal with their mothers when they had experienced this intervention.
Also on the 3rd day of life maternal depressive symptoms were higher in the group randomized to only see their infant for 5 minutes. This was in spite of controlling for factors expected to confound the result. Salivary cortisol did not show a difference at 4 months. While the study was underpowered for the secondary outcomes there was no increase rate of IVH or other adverse outcomes in the study so take that for what its worth.
Lastly, there was less hypothermia in the group randomized to STS care on admission.
Some lessons from this study
As the authors note it is possible that parents prepped themselves for the videos but the number of parents that “put on a show” should roughly be equal between the groups. Not sure given the low number of patients in the study if that would have truly balanced out but the results to me seem plausible. Having a preterm infant for most families who really don’t know what to expect can be a terrifying experience. Such parents may develop the vulnerable child syndrome in which parents hover over their children feeling as if they need to be over protective given the perceived frailty of the child. This constant worry can lead to stress for the family and affect the parent-child interaction. What if you were able to hold your baby though almost from the start for 45 minutes against your chest and see that your infant wasn’t as fragile as you might have thought? Could this lead to a reduction in depressive symptoms by 3 days as found here? Might you spend a lot more time in kangaroo care as the journey of the patient continues in the NICU?
These were not all healthy babies as about 80% in both arms received the LISA procedure for administration of surfactant and then went on to CPAP. To most parents these babies would have indeed appeared fragile but perhaps showing the families that the babies were stronger than they looked and moreover allowing the families to not just be observers but provide direct care indeed had an impact on their mood and that carried over to childhood.
No doubt the naysayers out there will want a larger study that looks at other outcomes in terms of harm such as IVH and sepsis but this study certainly shows the strategy is possible and may just have enough benefit to make it standard of care some day.
“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.
A Mother’s arms are full of tenderness and children sleep soundly in them – Victor Hugo
The NICU is a loud and chaotic place, that can be painful to be in at times. Its hard to get a good nights sleep (especially for the nurses!). When you think about how much our infants are handled and disturbed, poked and prodded, all in almost continual daylight, it’s a wonder they get any sleep.
For normal neurodevelopment the infant needs both active and quiet sleep. Sleep in an infant is divided into REM (active sleep) and NON-REM (quiet sleep). During quiet sleep you see very little movement and a regular breathing pattern, whereas active sleep involves movement with an irregular breathing pattern.
The importance of Quiet Sleep:
• Without it, the infant doesn’t get enough active sleep.
• Provides the infant with a break from the busy NICU environment.
• Lessons the release of glucocorticoids (Increased cortisol can cause neuronal cell death).
• Necessary for brain development.
• Increased quiet sleep = decreased risk of SIDS.
The importance of Active Sleep:
• Active sleep promotes brain maturation (US DHHS, 2003; Mirmiran, 1995).
• Most memory consolidation and learning occurs in this state (Smith, 2003).
• Nerve cell connections are restructured (synaptic plasticity) (Marks et al., 1995).
Due to the NICU environment, the infant ends up having slower sleep organization maturation and with increased cortisol they are more apt to have a disturbed and less restful sleep.
A complete cycle of sleep includes moving from active sleep to quiet sleep and back to active sleep. Full term and preterms >32 weeks postconceptional age will need about 60-70 minutes for a cycle. Infants <32 weeks postconceptional age will need about 90 minutes. So when infants come out for KC, we try to plan for at least that amount of time.
You will see when infants are placed in KC, the infant settles and goes into a deep sleep. To accommodate this, you will need comfortable chairs for the parent and good support for their arms. You also want to make sure they have had something to eat or drink, pumped breast milk, used the washroom and had something for pain if needed. Don’t be surprised if your parent falls asleep as well; oxytocin will end up kicking in (the cuddle hormone) and they often find it hard to stay awake. We also provide warmed blankets for our parents to encourage everyone to get comfortable and rest. Snoring is a common side effect of KC in our unit…
While in KC, the infants have a deep sleep with less arousal and better sleep organization than when not in KC (Ludington-Hoe et al., 2006)
In Scher et al.’s study (2009) they found that infants’ brain maturation was accelerated and brain complexity increased with 1.5 hours of KC/day for 4 days/wk from 32-40wks pma. Enhanced development in five sensory areas of the brain was shown with KC that was not seen in infants who did not get KC (both preterm and full term).
With all the evidence pointing to KC being beneficial for a good night’s sleep, I find it difficult to understand why so many are skeptical of it!
Sleep is that golden chain that ties health and our bodies together – Thomas Dekker
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!
Hi, my name is Diane Schultz and Michael has asked me to write a series of posts on his blog about Kangaroo Care (KC). Seeing as I am one of the Champions (they call you that, but sometimes the word begins with a B) for KC in my unit, I was thrilled. I thought I would begin with an introduction as to why I want to write about this.
I have been a Neonatal Nurse for 29 years working in the NICU at St. Boniface Hospital in Winnipeg. I felt that I had always given good care to the families but did not really make connections with them.
I was fortunate enough to meet Dr. Susie Ludington about 10 years ago at an Academy of Neonatal Nursing conference. She was a general session presenter and was speaking about Kangaroo Care. The first thing she said was “My goal is Kangaroo Care 24/7”. All I could think of was WTF!? I would have to listen to this Nutbar for an hour? Our unit had been doing KC for years but only occasionally and usually the parent would ask for it, we certainly did not promote it or do it with our more fragile infants.
After listening to Dr. Ludington present, my world changed. What she said hit a cord; she presented benefit after benefit with rationale and evidence that made complete sense to me. I felt guilty I had not been doing this at work and guilty that I had not held my own daughters this way. I am now lucky to be able to call Dr. Ludington a friend, and know she has changed my life.
Now, there is a lot of evidence out there touting the benefits of KC, but the real way to understand and believe in it is to do it. KC creates its own evidence. Every time I bring out a medically fragile infant to be held in KC, I know that this is the right place for that infant to be: with their parent being held. You can see the relaxation on all of their faces (decreasing cortisol), the infant is able to go into a deep sleep (promotes brain maturation), and the family is able to connect in the best way possible. I feel KC is as important as anything else we do at the bedside and is an extremely necessary therapy.
Promoting KC in my unit has benefited me at so many levels; I believe it has actually saved my career and given me a focus that I didn’t have before. You can’t help but make connections with your families, and these families are able to make connections with their little ones. KC is also a very important part of Family Integrated Care, as this is something that the family can contribute to their child’s care.
I also couldn’t be more proud of my unit; the staff I have the pleasure to work with are some of the best health care professionals around. They make every effort to bring our fragile infants out for KC and it has become part of our culture in our NICU. KC happens in our unit with almost all of our infants, the only exceptions being actively cooling babies and infants with chest tubes. We have also created a Standard Work Protocol so all medically fragile infants come out the safest way possible without creating extra stress on the infant or family.
In my series of posts I will present the many benefits of KC for infants and their families and share some of my experiences. I hope you will be able to take something away from this, begin to try KC in your own unit, and create your own evidence.
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!