KANGAROO MOTHER CARE

POLICY Kangaroo Mother care (KMC) offers physiological and psychological benefits for the infant and parents. It is important to begin KMC the first day of life or as soon as possible.

KMC is a method of holding whereby infant is placed skin-to-skin, chest-to-chest on parent's bare chest in an upright position wearing only a diaper. Parents or other family members identified by parents can participate in KMC. A minimum of 1 sleep cycle or 90 minutes duration is recommended to maximize the benefits of KMC.

RESEARCH EVIDENCE SUPPORTING KANGAROO MOTHER CARE: Benefits include: • Improved or maintained physiologic stability (respiratory rate, body temperature, decreased apnea and desaturations) • Promotion of quiet sleep • Reduction of stress and procedural pain • Improved parental attachment and confidence. It is important to note that even for ventilated infants; evidence suggests that KMC may assist recovery 1 from respiratory distress.

APPLICABILITY AND CONSIDERATIONS:

2 >30 weeks GA and older. • Good evidence to support KMC in this group

≤ 29 weeks GA. Consider: • Temperature Stability • Stability with respect to heart rate, respiratory rate and oxygen saturations during and after KMC.1 2

Relative Contraindications TEAM DISCUSSION IS REQUIRED PRIOR TO KMC FOR THE FOLLOWING INFANTS:

• Palliative 6 • Infants <28 weeks that are < 3 days old • Brainz Monitoring

Contraindications • Jet Ventilation • Non invasive ventilation (NIV) – red status • Infants on High Frequency Oscillating Ventilation (HFOV) on the Oscillator 3100A • Chest tubes 1 Swinth, Anderson & Hadeed (2003) 2 Ludington-Hoe, Morgan & Abouelfettoh (2003) 1 Maastrup & Greisen (2010) 4 Van Zanten (2007 5 Bauer (1998) 6 Kymere (2012)

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• Unstable Blood Pressure within 48 hours • Paralyzed infants • Clinical deterioration within the past 12 hour period. • Prolonged, frequent or severe apnea or bradycardia requiring Positive Pressure Ventilation (PPV) wih thin t e past 12 hour period • Early postoperative or post procedure period

Temperature Stability: • During the first week of life, some infants <27 weeks have difficulty maintaining their temperature. • Assess the infant’s temperature prior to transfer to establish a baseline. Reassess the temperature 30min after transfer. • Cover the infant with warm blankets and hat as needed. • Reassess the temperature prior to transferring the infant back to the incubator.

IV Lines: • Umbilical lines (UAC, UVC) must be assessed prior to each KMC event to ensure the line is secured. There must be an assessment of the sutures and the tapes by the Registered Nurse. • PICC line and PICC dressing must be assessed by the RN prior to transfer.

Respiratory Support: • If infant is intubated, a Registered Respiratory Therapist (RRT) must check the securement of the Endotracheal Tube (ETT) prior to and after the transfer. The RRT must be present during transfer. • Infants that are on NIV and are yellow status must have an RRT or RN present for transfer. • Infants that are on NIV and are green status, on high flow nasal prongs or in room air must have a care provider present to perform transfer. Parents who have received education and have demonstrated their ability to transfer their infant may transfer their infant independently. Parents will notify a healthcare provider (RN/RRT) prior to transfer to ensure that a healthcare provider is available for assistance if needed.

PROCEDURE Procedure Notes 1. Consider availability of RN and RT staff An RN and RRT are required to ensure stable position prior to offering skin to skin for ventilated of lines and ETT during transfer to and from holding infants position. 2. Gather supplies: posey and elastic band Ensure parent comfort prior to KMC session including to secure ubing, two cotton crib sheets meals, bathroom, pain control, drinking water, reading or a KMC wrap and a gown for the material and pumping. parent. 3. Set-up comfortable environment with a chair, footstool and privacy screen (as desired). 4. Assess infant’s vital signs, BIIP score, and securement of lines and tubes. 5. Remove infant’s clothing and have infant A hat is recommended for infants < 1000 grams. in a diaper only.

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Procedure Notes 6. Discuss with parent the expected Explain the recommended duration of KMC hold is min duration, sequence of steps involved in 90 mins but team will respond to infant cues as the transfer and their role of picking up needed e.g. sudden deterioration of vital signs. their infant during the transfer. Minimize stress during infant transfer. Infant may find the transfer stressful. Needs to be calm and deliberate.

7. Identify and obtain necessary family and See above. staff to assist with transfer. Parent lifting transfer method (preferred method) follow steps 8 to 15 then continue to step 21 8. Parent stands facing the incubator. Position chair towards incubator to minimize amount of turning during transfer.

9. Parent places hands, palms up under their infant.

10. Use one hand to support infant’s head and the other hold infant’s hips.

11. A second person supports lines and RRT to stand at the head of bed (HOB) to assist with tubing. the transfer of intubated. RN or RT presence required RRT present to support ventilator tubing, for NIV yellow status infants. ETT, RN supports parent with the transfer process and maintains integrity of lines, leads and other tubing

12. Parent brings infant to their chest (xiphoid

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Procedure Notes process to xiphoid process).

Ensure the infant’s arms and legs are flexed.

13. Have the parent sit down in chair. 14. Assist parent to secure the infant using rthe KMC w ap. Nurse/Infant transfer method steps 15 to 29 (if parent unable/uncomfortable lifting) 15. Have parent sit in chair with securement RN to parent transfer occurs when the parent is sheets/ KMC wrap in place. unable to lift their infant and/or sit down while holding their infant. Consider nurse/infant transfer when the mother is in the early post operative c-section period or when a parent has a medical reason that would prevent a safe parent lifting transfer. 16. Place hands palms up under the infant. See above picture 17. Use one hand to support infant’s head See above picture and the other hold infant’s hips. 18. A second person supports lines and RRT to stand at the HOB to assist with the transfer of tubing. intubated or NIV red or yellow status infants. RRT present to support ventilator tubing, ETT, and CPAP interface

19. Transfer infant slowly. 20. Place infant xyphoid process to xyphoid process and secure infant using securement sheets / KMC wrap. Parent Lifting or Nurse Transfer Steps 21-29

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Procedure Notes 21. Secure lines and tubing to the parent’s gown with a posey.

Ensure respiratory tubing is secured to allow water to drain away from the infant’s airway.

22. Cover infant with parent’s shirt or gown Avoids outward convective and evaporative heat loss. and blanket if necessary. Monitor temperature as indicated above. 23. Ensure emergency equipment is Bag/mask & suction must be outside of the incubator. accessible and within easy reach of Test equipment to ensure it is functional and will reach infant. the infant after transfer. Test equipment to ensure it is functional. 24. Continue all routine care and A change in vital signs during/after transfer may occur surveillance. but should return to baseline. Be patient and attempt to troubleshoot without moving infant back to the incubator.

Routine care such as vital signs, heel sticks, and gavage feedings can be completed during holding. This is less stressful than moving infant back to incubator.

Ensure parent is aware of a staff member available for support if required. 25. Educate and inform parent to: If a non-ventilated infant shows hunger cues, mother i. Recognize and respond can be encouraged to loosen securement sheets and to infant’s behavioral cues. slide her infant into a football hold allowing any attempt to lick or latch at the nipple. ii. The need for nurse to re- assess IV lines or ventilator tubing if parent Suggest ways parent can interact with their baby has moved around (while infant is awake) such as giving finger to grasp, significantly reading to their baby or singing. iii. Identify that in this situation with infant Stoking infant can be over-stimulating. Firm touch is

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Procedure Notes monitored that it is ok for more supportive. parent to dose off but ideally if parent is falling asleep to put the infant back in their bed. Review principles of safe sleep that parents need to be aware of for home practices 26. Assess IV lines (UVC, UAC, PICC, PIV) that cannot be easily visualized minimum q1h. 27. Use same transfer method to return Check infant’s temperature prior to transfer. infant to incubator. 28. Assess ETT position after holding 29. Assess the need to provide cares after If the infant is in deep sleep and cares are not transfer. necessary, allow infant to sleep undisturbed.

DOCUMENTATION • Length of KC hold on flow sheet • Variances in nursing notes LINKS TO RELATED DOCUMENTS: • Thermal regulation for Preterm Infant <32 weeks – Policy & Procedure • Appendix A & B – Securing infant skin to skin with mother & father • Appendix C – Securing lines and ventilator tubing when infant skin to skin

REFERENCES Bauer, K. et al. (1998) Effects of gestational and postnatal age on body temperature, oxygen consumption, and activity during early skin-to-skin contact between preterm infants of 25-30-week gestation and their mothers. Pediatric Research. 44(2). 247-251 Bergman, Nils (2004) Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200 – 2199 gram newborns. Acta Paediatr 93, 779-785 Bergman, Nils (2009) www.kangaroomothercare.com Calgary Health Region. Women’s and infant health. policy and procedure. Kangaroo care. April 2001 DiMenna, L. (2006) Considerations for implementation of a neonatal kangaroo care protocol. Neonatal network. 25(6). 405-412. Kledzik, T. (2005) Holding the very low birth weight infant: skin-to-skin techniques. Neonatal Network. 24(1). 7-14. Kymere, G. (2012). Skin-to-skin care for dying preterm newborns and their parents – A phenomenological study from the perspective of NICU nurses. Scand J Caring Sci, 2013(27). 669–676

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Ludington-Hoe SM, Morgan K, Abouelfettoh A. (2003). A clinical guideline for implementation of Kangaroo Care with premature infants of 30 or more weeks postmenstrual age. Advances in Neonatal Care 8 (3S). S3- S23. Maastrup, R, Greisen, G. (2010). Extremely preterm infants tolerate skin-to-skin contact during the first weeks of life. Acta Paediatrica, 99, 1145 -1149. Neu, M., Browne, J. V., Vojir, C. (2000) Impact of two transfer techniques used during skin-to-skin care on the physiologic and behavioral responses of the preterm infant. Nursing Research. 49(4), 215-223. Roberts, K., Paynter, C., McEwan, B. (2000) A comparison of kangaroo mother care and conventional cuddling care. Neonatal network. 19(4), 31-35. Swinth, J., Anderson, G., Hadeed, A. (2003) Kangaroo (skin-to-skin) care with preterm infant before, during and after mechanical ventilation. Neonatal Network. 22(6), 33-38. Van Zanten, H.A., Havenaar, A. J., Stigt, H.J.H., Ligthart, P. A. H., Walther, F.J. (2007). The kangaroo method is safe for premature infants under 30 weeks of gestation during ventilatory support. Journal of Neonatal Nursing. 13, 186-190.

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