1. Kangaroo Care and the Ventilated Neonate
Introduce yourself.
By Karen Black (MNursSci, RNC)

2. Kangaroo Care (also known as Skin-to Skin Contact)
Was developed by Rey and Martinez (1983) in Bogotá, Columbia as an alternative to incubator care (WHO, 2003)
Was initially defined as: “The care of preterm infants carried skin-to-skin with the mother.” (WHO, 2003)
Its key features were described as:
Early, continuous and prolonged skin-to-skin contact between the mother and the baby.
Exclusive breastfeeding (ideally)
Being initiated in hospital and continued at home
Providing small babies with the opportunity to be discharged early (WHO, 2003)
Kangaroo Care was first presented over 2 decades ago by Rey and Martinez in Bogotá, Colombia, where it was developed as an alternative to inadequate and insufficient incubator care for those preterm newborn infants who had overcome initial problems and required only to feed and grow.

3. Current definition of Kangaroo Care:
“A form of parental caregiving where the newborn low birthweight or premature infant is intermittently nursed skin-to-skin in a vertical position between the mother’s breasts or against the father’s chest for a non-specific period of time.” (Kenner & Lott, 2003)
Since its conception definitions of KC have varied and in Great Britain it is now understood to be a form of parental caregiving where the newborn LBW infant is intermittently nursed skin-to-skin in a vertical position between the mother’s breasts or against the father’s chest for a non-specific period of time (Kenner & Lott, 2003).

4. Benefits of Kangaroo Care
Maintaining physiological stability.
Increasing immunity.
Optimising breastfeeding.
Facilitating parent-infant bonding
(Shiau and Anderson, 1997; WHO, 1997; WHO, 2003).
A compelling body of literature supports the practice of Kangaroo Care in all stable infants over the age of twenty-eight weeks gestation, irrespective of financial setting, due to benefits in maintaining physiological stability, increasing immunity, optimising breastfeeding and facilitating parent-infant bonding (Shiau & Anderson, 1997; WHO, 1997; WHO, 2003).
In their 2003 publication’ Kangaroo Mother Care: a practical Guide’ the World Health Organisation (2003) state that the benefits of Kangaroo Care offer more than an alternative to incubator care, saying that it offers an effective way to meet baby’s needs for warmth, breastfeeding, protection from infection, stimulation, safety and love across all health care settings.

5. Kangaroo Care as an alternative to cots in rural Tanzania
Each year some 20 million low-birth-weight (LBW) babies are born mostly in less developed countries due to preterm birth and impaired intrauterine growth, These infants contribute substantially to the extremely high rate of neonatal mortality associated with extreme poverty. Representing an more than a fifth of infant deaths each year.
The care of these premature infants is often a burden for health and social systems everywhere. I had the opportunity to witness this first hand whilst working at a rural hospital in Central Tanzania (East Africa) earlier this year. At Mvumi modern technology such as incubators were not available, and even if they were provided by the west they could not have been used properly due to the shortage of trained staff, the intermittent power supply and the lack of clean water to wash them adequately between use. That isn’t even mentioning the fact that supplying incubators to meet the demand necessary in an area where most woman have over 10 babies as only ¼ of them survived their infant years! Having said that the hospital did have an incubator at one point but it was discovered that instead of promoting benefit this technology became a huge barrier between mothers and their infants and led to problems with bonding and feeding.
In this setting good care of preterm and LBW babies is very difficult, with hypothermia and opportunistic infections jeopardising the already poor chance of survival. At present these babies are cared for in a special room which is kept hot and humidified (as the power supply allows) were they are wrapped in blankets and placed in washing up basins beneath mosquito nets. To me it was obvious that Kangaroo Care would offer far greater benefits than the set-up already established at this hospital as it would meet the babies need for warmth, assist in the establishment of breastfeeding (especially considering that bottle feeding is not a safe option), provide greater protection from infection whilst offering increased stimulation and opportunities for bonding.

6. In a setting as affluent as our own to what extent should Kangaroo Care be promoted?
However in a setting such as our own where there is a wealth of modern neonatal care technologies and a comparative wealth of highly specialised and skilled health professionals questions arise as to what extent Kangaroo Care should be practiced?
A Cochrane review published in 2003 stated that although Kangaroo Care appears to reduce severe infant morbidity without any serious adverse effect reported, there is currently insufficient evidence to recommend its routine use in LBW infants. Further well designed randomized controlled trials of this intervention were recommended.
On units were I have worked Kangaroo Care is widely promoted to all stable infants who are now on the unit ‘feeding and growing’. But was witnessing the initiation of this practice with ventilated intensive care infants, particularly those who were LBW or very premature, where my brain started ticking and I began to question the extent this practice should be promoted?

7. Kangaroo Care and the Intensive Care Infant
Cochrane review states that Kangaroo care should not be routine practice in the technological setting. (Conde-Agudelo, et al, 2003)
Decision to ‘Kangaroo’ infants generally left to individual nurses clinical judgment (Nyqvist, 2004).
Many infants miss out on opportunity to consider this practice.
In my limited experience there is generally an acceptance that if a neonatal nurse caring for an intensive care infant, ventilated or not, feels that the baby and parent would benefit from Kangaroo Care then she is at liberty to promote its initiation. Whilst this recognition of each nurse as an autonomous practitioner is generally seen as a positive concept, increasing job satisfaction and quality of care provided (Mrayyann, 2004), I felt that in this instance some form of regulation was required to ensure all infants were given the same opportunities. This opinion was reinforced when I witnessed one intubated infant receiving KC where it appeared that both mother and child benefited as both displayed signs of decreased stress during the KC period and the mother later told me of the immense satisfaction and enjoyment she received from holding her infant skin-to-skin.

8. Aims and objectives
To examine the application and limitation of Kangaroo Care with intubated LBW or very premature infants requiring mechanical ventilation.
To critically examine the literature.
To provide recommendations for practice.
This paper aims to examine the application and limitation of KC amongst intubated LBW or very premature infants requiring respiratory support by means of mechanical ventilation on Neonatal Intensive Care Units (NICU’s) in Great Britain and provide recommendations for practice (See Appendix A for definitions relating to this assignment). This will be done through critical reflection, using Driscoll’s (2000) ‘What model of structured reflection’ to explore experiences in practice, and through critical examination of relevant literature.

9. Physiological Stability
Researcher(s)
Type of Study
Sample group
Findings
Drosten-Brookes (1993)
case study 2
● Infants responded to Kangaroo care with increased quiet sleep and decreased Oxygen requirement ● Highlight possible benefits and need for further research.
Gale, Frank & Lund (1993)
Quantitative 25
● During KC period pulse, oxygen and respiratory rate remained within normal parameters for infants of ≥30/40 or >1.2kg ● Infants <30/40 or <1.2kg showed signs of restlessness, tachycardia and decreased oxygenation during prolonged kangaroo care.
Ludington-Hoe, Ferreira & Goldstein (1998) 1
●a 27-day old neonate weighing 894g received SIMV at a rate of 12 breaths per minute whilst receiving Kangaroo Care for 45minutes.
Ludington, Ferreira & Swinth (1999) 12
●The physiological observations of Infants <1kg remained stable during KC and decreased oxygen requirement.
Smith (2001) 14
●Infants oxygen requirements increased and body temperature dropped.
The use of KC amongst ventilated infants was first presented as a case study demonstrating that two ventilated infants responded well to KC, showing signs of increased quiet sleep and decreased oxygen consumption (Drosten-Brookes, 1993). Whilst the main focus of this article was on preparation of parents and staff for KC and the extremely small sample group negated transferability of results, this case study highlight that KC may have benefits amongst ventilated infants. Following this a study by Gale, Frank & Lund (1993), involving twenty-five ventilated infants, indicated that during KC temperature, pulse, oxygenation and respiratory rate remained within normal parameters for infants of thirty to thirty-three weeks gestational age or weighing between 1.2-3kg. However, infants weighing less then 1.2kg or younger than 30 weeks gestational age showed signs of restlessness, tachycardia and decreased oxygenation during prolonged periods of KC. As only twenty-five infants were recruited in this quantitative study the findings may not be transferable to other infants. Furthermore, due to poor methodological quality other variables may have been interacting in physiological observations observed, such as medical status or positioning of hold. However, whilst not providing any answers this study indicated that KC may be safely practiced with some intubated neonates and therefore acted as a catalyst for further studies.
More recent research by Ludington, Ferreira and Swinth (1999) involving twelve ventilated very premature infants weighing less than 1kg indicated that physiological observations remained stable during KC and oxygen requirement decreased. Whilst these perceived benefits of KC with small infants apparently contradicts findings by Gale et al (1993) advances in health care technology in the 6 years separating the studies may account for discrepancies in results. Again, this study had an insufficient sample group for the methodology used; however the rigorous methodology could indicate benefits of KC with LBW infants in other centres.
On the other hand, results from Smith’s (2001) quantitative study involving fourteen intubated LBW infants were contradictory to Ludington et al’s (1999) results. Smith found that infants experienced increased oxygen requirement, and experienced an overall reduction in body temperature. However, in this study infants were on average thirty-four days post-birth, still requiring ventilation and all had been diagnosed with chronic lung disease. Therefore, due to the decreased physiological stability related to infants with chronic lung disease, these findings may not be generalisable to infants of younger gestational age who have not yet acquired this condition, as demonstrated in other studies. Moreover, the variation in results between studies may be due to other interacting factors such discrepancies in technologies used to measure physiological stability, differences in room temperature, positioning of KC holds or nurses ability to transfer infants competently.

10. Transfer Technique
Indicated to be the greatest contributing factor to heat loss and increased stress, resulting in tachycardia or apnoea (Ludington-Hoe et al, 1998)
Lifting commonly associated with oxygen desaturation (Danford et al, 1983; Peters, 1992).
Physiological disruption occurred in both parent and nurse led transfer techniques (Neu et al, 2000).
Involving 2-3 nurses in transfer minimises the risk of extubation or physiological disruption (Ludington-Hoe et al, 2003).
A major factor affecting physiological stability during KC in ventilated infants is transfer technique: Ludington-Hoe, Ferreira, and Goldstein (1998) indicated that this is the greatest contributing factor to heat loss and increased stress, resulting in tachycardia or episodes of apnoea.
Additionally, the transfer of the infant into KC involves positioning and lifting, similar to that used during weighing or radiographic procedures, which have been associated with oxygen desaturation (Danford, Miske, Headley & Nelson, 1983; Peters, 1992).
In their quantitative study involving fifteen intubated LBW infants Neu, Browne and Vojir (2000) noted that although the infants experienced some physiological or behavioural distress during both parent and nurse led transfer, observations quickly returned to baseline levels during and after skin-to-skin care regardless of the transfer method employed. Whilst there is some degree of physiological disruption associated with transfer into KC it has been indicated that during skin-to-skin contact infants’ can experience less variation in oxygen saturation and heart rate the during pre-KC period, plus improved muscle tone and ability to employ self-regulatory manoeuvres (Neu et al, 2000).
These positive outcomes affirm the decision to undertake KC in spite of initial stress caused by transfer.
Ludington-Hoe et al (2003) proposed that in order to reduce impact of transfer into KC on physiological status 2-3 nurses should assist in moving the infant from incubator to mother in order to ensure that the process is swift, thus reducing heat loss and distress. Moreover, involving 2-3 nurses minimises the risk of extubation or any other monitoring leads and intravenous lines becoming dislodged whilst decreases the amount of time that ventilation system is disconnected for (Ludington-Hoe et al, 2003).
I feel it should be noted at this point that no detailed studies regarding physiological stability have been undertaken in Britain; rather the majority were carried out in the United States of America. Whilst these discrepancies in health care systems may negate some findings, on the whole it could be stated that neonatal care is similar in both countries.

11. Breastfeeding
The diverse range of benefits of breastmilk for premature infants are widely documented.
Admission to NICU and necessity for intubation affects decisions to breastfeed (Jaeger et al, 1997).
Those who chose to breastfeed often have difficulty establishing expression and sufficient supply during period of intubation and tube feeding (Furman and Kennell, 2000).
Whilst considering the positive and negative outcome of KC its impact on breastfeeding must be taken into account. There is compelling evidence that due to superior nutritional qualities and immunologic benefits, breastmilk is the optimal food for all infants, regardless of gestational age. Moreover, specific benefits of breastfeeding preterm infants include decreased rates of specific neonatal morbidities such as infection, improvement in cognitive-developmental outcome, and increased maternal satisfaction (Kavanaugh et al,1997). However, Jaeger et al (1997) demonstrated that whilst a mother may appreciate the benefits of breastmilk, factors such as separation from infant, stress caused by admission to NICU and fear of expressing milk can affect her decision to breastfeed following premature delivery. Also, it has been indicated that mothers of infants admitted to NICU, particularly those whose infants are ventilated and require feeds via gastric tube, often find it difficult to establish breastmilk expression and continue producing sufficient milk (Furman & Kennell, 2000). This may be due to the complex stress and anxiety emotions often triggered in the NICU by the overwhelming atmosphere harboured in the intensive care environment (Furman & Kennell, 2000). It has been indicated that these stress and anxiety emotions can reduce a mother’s ability to produce sufficient milk supplies by disturbing the endocrine process involved in milk production and expression (Riordan & Auerbach, 1999).

12. Advantages of Kangaroo Care to breastfeeding
Stimulates endocrine pathway and enhances flow of milk (Bier, 1997; Whitlaw et al, 1998).
Reduces harmful anxiety and stress emotions (Whitlaw et al, 1998).
Promotes family centred care and breaks down barriers to expression of milk (Jaeger et al, 1999).
However, research has shown that, due to stimulation of this endocrine pathway, mothers of preterm infants participating in KC produce larger volumes of breast milk and lactate for longer periods than mothers who do not undertake this care (Bier, 1997; Whitlaw, 1998). Whilst these studies were undertaken on stable, non-intubated premature infants the hormone production stimulation associated with skin-to-skin contact is relevant to mothers of ventilated infants. Moreover, KC has been shown to reduce the harmful anxiety and stress emotions experienced by mothers in the NICU, and thus skin-to-skin care would enhance the occurrence of successful breastfeeding with ventilated infants through the reduction of negative consequences of these emotions. Furthermore, as with all preterm infants, mothers’ anxiety associated with fear of expression of milk for ventilated infants can be combated by the nurse encouraging them to consider expression, assisting in initiating it as soon after birth as possible and offering help in maintaining lactation by facilitating opportunities and knowledge to express often enough (Jaeger et al, 1999). This education and empowerment in promotion of breastfeeding would serve to promote family centred care: a practice which nurses are obligated to undertake (Latto, 2004). As KC offers a means to optimise breast milk production and aid expression, educating parents about this care would further serve to address the concept of family centred care.

13. Parental benefits of Kangaroo Care
Reduction in stress and anxiety improves parents perception of the infants’ admission to NICU and subsequent ventilation (Legault & Goulet, 1995).
Reduces feelings of inadequacy, anxiety and frustration experienced by fathers (Neu, 2004).
Facilitates closeness and bonding (Neu, 2004).
Case reports detail benefits in reducing complications associated with maternal eclampsia (Anderson et al, 2001) and post-natal depression (Dombrowski et al, 2001)
In addition to optimising production and expression of milk, the reduction of stress and anxiety associated with KC could serve to improve mother’s perception of the infants’ admission to NICU and subsequent ventilation (Legault & Goulet, 1995). Moreover, it has been indicated that fathers are also affected by feelings of inadequacy, anxiety and frustration associated with NICU admissions (Affleck & Tennen, 1991; Affonso et al 1992; Neu, 2004). Furman and Kennel (2000) postulated that KC facilitated feelings of closeness and helped parents to rectify complex emotions experienced in the NICU whilst forming a bond with their newborn. Additionally, Neu (2004) reiterated that the positive emotions experienced during skin-to-skin contact decrease negative emotions experienced by parents in this intensive environment.
Case reports exist documenting the efficacy of KC in ameliorating complications associated with maternal eclampsia (Anderson et al. 2001) and post-natal depression (Dombrowski, Anderson, Santori, & Burkhammer, 2001). Although benefits have also been reported through the more traditional approach of parents cuddling their child via blanket holding, two studies have reported increased satisfaction following the practice of KC (Gloppestad, 1998; Legault & Goulet, 1995). As nurses have an obligation to address the health and wellbeing needs of both infant and parents (NMC, 2002), thus fulfilling the concept of family centred care, information should be given to parents regarding the reported parental benefits of skin-to-skin contact versus other methods of holding.
It must be highlighted that the majority of parents involved in studies reporting parental satisfaction of KC did not encounter problems during skin-to-skin contact. However, there are numerous risks associated with KC of ventilated infants including dislodgement of venous or arterial lines and extubation. If accidental extubation or access dislodgement where to occur during KC this would undoubtedly increase parental stress and anxiety, and may lead to feelings of guilt and fear, thus negating the documented positive parental outcome. Moreover, this risk has implications towards physiological stability and the safe practice of KC amongst intubated infants. Furthermore, it should again be noted that most research reporting parental satisfaction of KC comes from hospitals outside the UK. Due to cultural opinions regarding expression of emotion and views on participation in the practice of skin-to-skin care not all finding may be directly transferable to British parents.

14. Adverse effects of Kangaroo Care
Increased stress on dislodgement of venous or arterial lines or accidental extubation.
Feelings of guilt if infant becomes physiologically unstable during Kangaroo period.
It must be highlighted that the majority of parents involved in studies reporting parental satisfaction of KC did not encounter problems during skin-to-skin contact. However, there are numerous risks associated with KC of ventilated infants including dislodgement of venous or arterial lines and extubation. If accidental extubation or access dislodgement where to occur during KC this would undoubtedly increase parental stress and anxiety, and may lead to feelings of guilt and fear, thus negating the documented positive parental outcome. Moreover, this risk has implications towards physiological stability and the safe practice of KC amongst intubated infants. Furthermore, it should again be noted that most research reporting parental satisfaction of KC comes from hospitals outside the UK. Due to cultural opinions regarding expression of emotion and views on participation in the practice of skin-to-skin care not all finding may be directly transferable to British parents.

15. Evaluation of evidence
Benefits in breastfeeding, nutrition and parental satisfaction if undertaken safely.
Practice can benefit physiological stability if carried out for an appropriate length of time and utilising a safe transfer technique.
Kangaroo care can be conducive with mechanical ventilation.
It may be deduced from the evidence detailed that due to benefits in breastfeeding and parental satisfaction the application of KC amongst intubated infants may be advantageous. Moreover, it has been demonstrated in numerous studies that skin-to-skin care can improve, not deter physiological status in ventilated infants. Therefore it would appear that KC is conducive with mechanical ventilation.

16. Limits in research evidence
Compatibility of ventilation method.
Accessing haemodynamic stability.
Drug contraindications.
Limit of gestational age or size of infant.
Studies from British units.
Randomized control trials.
Lack of evidence depicting which neonates are suitable candiates eg. Haemodynamic stability, types of ventilation, drug contraindications.
However, the evidence available is scant, particularly in relation to which ventilated infants are not suitable for KC, such as those receiving high frequency oscillation ventilation or those without diagnosed sepsis. Additionally, there is a lack of evidence regarding the limit of gestation and size of infant conducive with the practice of KC: with decreasing limit of viability of newborn infants surviving, research depicting such limits is imperative. It would seem that more in depth multi-centre trials of KC with ventilated infants, particularly in Britain, are needed in order to ensure that the benefits of KC are generalisable and establish which infants would benefit from the practice. Whilst further research would ideally be in the form of randomized control trials, given the nature of participants, this criteria would be difficult to fulfil. However, providing methodology is otherwise rigorous, utilizing a non-random participant selection could still provide generalisable results.

17. Barriers to Kangaroo Care with ventilated neonates in practice
Medical staff reluctance
Difficulty administering care during KC
Staff concerns for parental privacy
Lack of experience with KC
Insufficient time for family care during KC
Belief that technology is better than KC
Fear of arterial or venous line dislodgement
Fear of accidental extubation
Safety issues for very low birthweight infants
Inconsistency in technique
Nurses’ feelings that their work load increased.
Nursing reluctance.
A recent American national survey of KC practice revealed that nurses are still reluctant to instigate this care, particularly with infants requiring mechanical ventilation (Engler et al, 2002). Once again, due to discrepancies in health care culture these results may not be entirely transferable to British nursing. Whilst ideally a similar study would be carried out in Britain, the American results give insight into barriers that may face all nurses working in the NICU, regardless of health care setting. Factors identified as barriers which deter nurses from undertaking this care, particularly with ventilated LBW babies, are displayed in Table 1.
The two main concerns expressed were intrinsically linked to the safety of the infant; namely security of intravenous and arterial lines, and a fear of accidental extubation (Engler et al, 2002). Engler et al (2002) suggest that a lack of uniform guidelines for practice and inconsistency in the way KC is carried out may contribute to these barriers. It has been shown that policies and protocols guide clinical activities and promote consistent quality care whilst providing nurses with legitimacy of their knowledge (Manias & Street, 2000). Subsequently it can be deduced that guidelines would be of benefit in this instance. Therefore, in order to combat fears regarding the safe practice of KC comprehensive evidence-based policy and protocol guidelines, such as that shown in Appendix B, should be developed and applied within individual NICU’s, thus increasing the safety and consistency of KC in practice.
(Engler et al, 2002)

18. This need for protocol is strongly recommended by the World Health Organization (2003) who state that every health facility that implements KC should develop a written policy and guidelines which incorporate clear criteria for monitoring and evaluation. Moreover, Engler et al (2002) highlight that practice guidelines developed should emphasise that the decision to implement KC needs to be made on an individual basis, with careful evaluation of the physiologic status and holistic care needs of the infant in question (NMC, 2002).

19. Recommendations for practice
Development of evidence based policy at Trust level.
Incorporate an inter-disciplinary approach.
Remain aware of limitations of policy implementation
However, it must be noted that , whilst an evidence based protocol may instigate the use of 2 or 3 nurses for transfer into KC, such staffing ratios may not be achievable in practice. Additionally, it may not be possible to achieve fully holistic and family centred care as staff availability or drug administration time may dictate when KC can be initiated. Subsequently, the extent to which an evidence base protocol can be implemented in practice may have its limitations.

20. Recommendations for education
Comprehensive education detailing the benefits and risks.
Up to date evidence based information.
Incorporated into new staff induction or learning beyond registration study days.
Encourage critical reflection on experiences of Kangaroo care with ventilated infants.
In view of other listed barriers to the practice of KC it is apparent that to overcome such impediments and increase the initiation of safe and effective skin-to-skin care with ventilated infants, neonatal nurses need to receive comprehensive education highlighting the research evidence supporting KC (Engler et al, 2002). Such a programme should also emphasize the value of skin-to-skin care for parents and infant bonding: thus addressing the need for family and patient focused holistic care. Alongside the initiation of policy and protocols this education would ensure standardisation of information given to parents avoiding the confusion highlight by Neu (2004).

21. References
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22. References continued
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