by All Things Neonatal | Mar 22, 2018 | Developmental care, kangaroo care, Neonatology, newborn
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%.
Surprising results?
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 |
| Variable |
SSC |
Isolette |
Difference in mean |
p |
| rStO2 |
73.6 |
74.8 |
-1.3 |
<0.01 |
| SpO2 (median) |
97 |
97 |
-1.1 |
0.02 |
| HR |
161 |
156 |
5 |
<0.01 |
| % time in quiet sleep |
58.6 |
34.6 |
24 |
<0.01 |
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!
by All Things Neonatal | May 11, 2017 | kangaroo care, Neonatal, Neonatology, outcome, Parents Corner
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
by All Things Neonatal | Apr 15, 2016 | kangaroo care
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.
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.
by All Things Neonatal | Apr 14, 2016 | kangaroo care
As the practice seems to be winning the world over you can imagine that a headline entitled,
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.
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!
by All Things Neonatal | Apr 14, 2015 | Developmental care, kangaroo care, Neonatology
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…
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
