Introduction
In our 15th podcast episode, we continue our discussion on kangaroo care. First, we address some of the common barriers to kangaroo care and discuss why it may not always be encouraged sooner or more often. Next, we review different ways to remove or minimize some of the common obstacles NICUs encounter that may prevent daily kangaroo care for parents. We then talk about readiness of the infant, parents, and unit for daily skin-to-skin care and discuss the few limiting factors that may prohibit an infant from being able to do kangaroo care.
Finally, I review the step-by-step how to guide for kangaroo care for the parents and nursing. We review how to prepare for kangaroo care each time and the different transfer methods commonly used. Finally, I share my top tip on how mothers can eventually pump while doing kangaroo care so it does not interrupt your time to hold your baby skin-to-skin.
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Video of Standing Transfer
Kangaroo Care Log
Episode 15
Common Barriers for Daily Kangaroo Care
In our last podcast episode, we reviewed kangaroo care and the numerous benefits for both the infant and the parents. If you have not had an opportunity to listen, I strongly encourage you to go back and listen to episode 14, Kangaroo Care in the NICU: How Does it Benefit the Infant and the Parents? We put together a great graphic that reviews the multiple benefits of kangaroo care for the baby and the parent that you definitely will want to review!
But, if you are a new parent, especially to an infant in the NICU, you may be wondering, how do I know if I can do kangaroo care with my baby? Is my baby stable enough to try? Is my baby too small? What about all of the tubes connected to them? How do I know what to do? What if I harm my baby? Have no fear! Today we will address your concerns and so much more!
Despite the well-known benefits to kangaroo care, there are still barriers that prevent consistent implementation of skin-to-skin care in the NICU.
For parents, they often have reservations about doing kangaroo care with their infant due to their overwhelming fear and anxiety. Oftentimes, they are concerned with how unstable their infant is and fear they may do more harm than good by doing kangaroo care. They also may not be fully aware of all of the benefits of kangaroo care for their baby and themselves.
For mothers, either due to the mode of delivery or additional postpartum complications, it may prevent them from being at the bedside to visit their baby and do kangaroo care in the first few days. They may also be dealing with swelling, breast pain, back pain, and/or incisional pain.
Many parents are also physically separated from their infants due to their infant being transferred to a different facility. The hospital may also be far from the parents home or there are limited resources for parents to stay near or at the hospital. It is very common for the parents to have limited time to visit the NICU due to work or additional responsibilities and other children at home.
The NICU environment itself is also a common barrier to frequent and regular kangaroo care. Each NICU is set-up differently, but units with open bay areas and limited individual bedspace can create physical barriers. The lack of space and limited availability of privacy screens coupled with a desire for a quiet atmosphere inhibit the ease of practicing daily kangaroo care. Even in NICUs equipped with private rooms, there may be limited chairs or recliners available for several parents to practice kangaroo care at once.
And sadly, despite the common knowledge of the many benefits of kangaroo care, the NICU care team may also limit the frequency or initiation of kangaroo care due to their personal beliefs. They may have limited time available due to their patient assignment or staffing issues. The staff may be resistant and not actively promote or encourage kangaroo care due to their ambivalent feelings toward it and/or due to their lack of recognition of the magnitude of its benefits. In a recent study, only 18% of nurses compared with 63% of mothers believed that kangaroo care should be provided to their infants on a daily basis.
The NICU care team may also not fully value or empathize with what it means for a NICU parent to be able to hold their baby and bond with them or oftentimes, they may not have been provided with appropriate education or adequate training to facilitate promotion of the practice.
Since kangaroo care is encouraged with very tiny and critical infants, there is often concern from the staff in their ability to facilitate safe kangaroo care. With critical infants, there are several pieces of life-saving equipment attached to the babies. It does take a significant amount of time, staff, and resources each time kangaroo care is practiced. Parents, then also become more apprehensive regarding daily kangaroo care. They are concerned that the breathing tube will become dislodged, that the infant will have a prolonged apnea, and even worse, that they were the ones to have caused it to happen. And sadly, despite following the appropriate protocols and having all of the best laid plans in place, the transition does not always go smoothly and lines do become dislodged. After one mishap, the parents become more apprehensive in their desire to continue daily kangaroo care and the NICU care team may also become more hesitant to promote it.
How to minimize barriers for daily kangaroo care
One of the most significant ways to remove the above barriers is to start by identifying them. Secondly, the nurses’ safety concerns that result in limited promotion of kangaroo care are best addressed with nursing education. With proper educational interventions and training, safe and low-stress transfers are possible each time with kangaroo care.
Not only should the staff be provided with education, but the parents as well. Parents should be educated on the benefits of kangaroo care, given practical advice and instructions on how to safely hold their infant.
Additionally, modification of the physical environment by providing privacy screens, comfortable chairs, and by providing family rooms or a place for them to stay will also support more frequent and regular kangaroo care.
Kangaroo Care NICU Policies
Research has also shown that having clear and concise policies in place for kangaroo care in the NICU will help guide consistent implementation of kangaroo care. Formal policies will minimize variation in the information parents receive regarding timing and appropriateness of skin-to-skin care, therefore reducing miscommunication and parental confusion.
Within the NICU policy, there should be clear guidelines for which infants are able to do kangaroo care including how to assess readiness, tolerance, and protocols describing the transfer of the infant from the isolette to the parent’s chest.
Some NICUs have a stoplight system that is displayed by the baby’s bedside so there is not a question if they are able to do kangaroo care. If it is a green light, there should be no limitations on the practice of kangaroo care. A yellow light calls for a discussion between the care team and parents daily during rounds. A red light reflects the infant’s inability to do kangaroo care based on exclusion criteria for that day.
It has also been shown to be helpful for NICUs to enroll unit-based champions to assist with implementing and promoting daily kangaroo care. Better yet, a multidisciplinary team with different NICU care team members including bedside nurses, respiratory therapists, providers, and/or physical therapists and occupational therapists will improve the NICU’s rates of daily kangaroo care. The team members are responsible for ensuring the success of the interventions put into place to increase the regular practice of kangaroo care as well as parent’s knowledge and comfort in providing it.
Which infants are unable to practice kangaroo care
As I have mentioned before, each NICU and their unit policies will vary and it is not any different with kangaroo care. The inclusion criteria for which infants are able to do kangaroo care will vary by institution. I will review which infants are typically unable to do kangaroo care based on recommendations and my personal experience, but please ask your unit for their specific criteria.
There are actually very few limitations for which infants are unable to do kangaroo care. References recommend delaying kangaroo care for infants with open abdominal wall or neural tube defects that are to be kept as sterile as possible prior to the repair. For infants who are freshly out of surgery and their stability has yet to be established, kangaroo care should be delayed. Infants with significant hemodynamic instability with unstable blood pressures, those who are experiencing severe heart rate drops, apnea episodes, or oxygen desaturations especially with handling should be delayed for the time being.
Most NICUs, and I reiterate MOST, will allow infants who are ventilated with an endotracheal tube be held skin-to-skin. It can be done routinely and successfully with proper education for the staff and parents and with adequate resources and team members each time the infant is transferred.
Some institutions may not let infants be held with a high-frequency ventilator but it will vary with each NICU. Where I practice, we do allow infants who are on the high frequency jet ventilator be held skin-to-skin assuming they are otherwise hemodynamically stable. Holding skin-to-skin can be a bit trickier with the high frequency oscillatory ventilator and some NICUs may not allow it.
With lines and chest tubes, I have seen and heard many variations from unit to unit. Some NICUs will allow kangaroo care with a chest tube in place. There are many variations with the allowance if the infant has an umbilical venous catheter or umbilical arterial catheter in place. The umbilical lines are an incredibly important part of the treatment plan for the infant and pose additional risks if they were to become dislodged. Specifically, with an umbilical arterial catheter, or any arterial line, the baby has the potential to lose a large amount of blood in a very short amount of time. With proper securement, it is more common for institutions to allow an infant to be placed skin-to-skin with an umbilical venous catheter, versus an umbilical artery catheter. Oftentimes, the infant is positioned more on their side against the parent’s chest for closer observation of the umbilical line. There are not typically any limitations for an infant who has a peripherally inserted central catheter (PICC) or central venous line (CVL) in place.
Lastly, due to the risk of intraventricular hemorrhage (IVH) in very premature infants or those less than 30 weeks gestation, many NICUs will delay kangaroo care for at least 72 hours after birth. With the incidence of intraventricular hemorrhage, 90% of them occur within the 1st 72 hours of life. Therefore, specifically during this time, there are several precautions taken to minimize the risk.
Many NICUs have very specific protocols or bundles of care for intraventricular hemorrhage prevention for infants less than 30 weeks. One key component in the protocol is to keep the infant’s head in a midline position and to minimize fluctuations in the cerebral blood flow with unnecessary movements. So although it is difficult to wait those 72 hours, I strongly recommend doing so in the best interest of your baby and their future.
For us personally, with William being a 23 weeker, we waited until his UAC line was removed and beyond his first 72 hours for our first time practicing kangaroo care. I held him skin-to-skin when he was around 112 hours of age or a bit over 4 days old and it was well worth the wait!
So although there are not many firm limitations for when an infant can participate in kangaroo care, there are a few that I felt were important to mention. But it is also important to point out that even if your baby does not have one of the aforementioned limitations, the ability to do kangaroo care with your baby will need to be evaluated each day. If your baby is in the NICU, you will quickly learn the ups and downs that you and your baby will experience during their NICU journey. So there may very well be days that it is recommended that you hold off on kangaroo care in the best interest of your baby. As always, discuss it with your baby’s care team.
Assessment of readiness of kangaroo care
As I previously mentioned, the NICU care team will need to assess readiness of not only your baby each day for kangaroo care, but also the readiness of you as the parent and the institution. The bedside nurse will assess your baby, their vitals signs, and general behavior and readiness for kangaroo care. They will also assess you as the parent and your readiness including your knowledge of kangaroo care, your willingness to hold, your previous experience with it and your emotional preparedness. Next, an evaluation of the resources available within the units needs to be done. Are there currently enough team members to assist with the transfer, is there a recliner and privacy screen available? Being prepared is one of the key components of successful kangaroo care for everyone involved!
What to prepare for kangaroo care
Before initiating kangaroo care, there are few important things to do and to have by your side before your sweet little one is skin-to-skin with you.
For the parents
- Use the restroom prior to practicing kangaroo care so your time will not be interrupted.
- For mothers, they should pump prior to initiating kangaroo care and remove their bra.
- Change into a hospital gown or a shirt that opens from the front.
- Consider cleansing your chest with appropriate wipes prior to kangaroo care especially for the most vulnerable NICU patients to minimize the spread of staph aureus that may lead to central line associated bloodstream infections.
- Ensure you have a snack prior to starting kangaroo care and water nearby.
- Gather the books you plan to read to your infant.
- Discuss with your baby’s nurse the way you prefer to transfer the baby onto your chest.
For nursing
- Assess infant’s readiness and vital signs before kangaroo care
- Gather a recliner, blankets, pillow and privacy screen
- Enable assistance from additional nursing staff and/or respiratory therapy for the transfer
- Change the infant’s diaper and place a hat on the infant
- Place the recliner beside the isolette or radiant warmer
- Discuss with the parents the preferred way to transfer the baby onto their chest and review expectations for the minimum length of time to do skin-to-skin care
Transferring the infant for kangaroo care
For the actual transfer, there are essentially two different types: the sitting or the standing transfer. The parents should be educated on the two different types followed by a discussion regarding which one the parents prefer.
For the sitting transfer, the mother or father prepare themselves and gather their water, books or any additional supplies needed. The parent sits in the chair and a pillow is placed on their lap. The nurse and additional staff prepare the infant and gather the tubing and wires. One nurse gently lifts the infant typically with a blanket or snuggly under them while another team member secures any IV lines, the endotracheal tube, and monitor wires. The infant is carried over and gently placed upright on the parent’s chest skin-to-skin with their head and neck in a slight sniffing position to maintain their airway. The infant should be placed in a flexed position. A blanket should be placed around the infant once they are in the proper position. The ventilator or respiratory tubing can be taped and secured over the parent’s shoulder. The recliner can be gently reclined to elevate the parent’s feet.
For the standing transfer, the mother or father prepare themselves and gather their water, books or any other additional supplies needed. The parent stands facing the open isolette. The nurses gather the tubing and wires, the parent or nurse holds the endotracheal tube and with a blanket or the snuggly underneath, the parent gently lifts their baby as they lean forward. The parent places their infant onto their chest in an upright position with their head and neck in a slight sniffing position. As someone holds the kangaroo chair in place the parent gently sits down with the infant on their chest and the nurses closely follow with the wires and tubing. A pillow can be placed on the parent’s lap for support. The tubing is secured and the chair is gently reclined.
For me, I preferred the standing transfer because I felt that I had beter control of placing William onto my chest. Once my husband saw me do it, he quickly learned the technique and always did the standing transfer himself. It may be intimidating initially to imagine lifting your tiny infant by yourself with all of the attached tubes and wires, but I encourage you to consider trying it if you have not done so already.
When William was still intubated and in the NICU, my friend took a video of me doing the standing transfer method. To see it, click below.
Most beneficial length of time for kangaroo care
Once you are settled in with your baby during kangaroo care, consider reading to them or softly singing to them. Try to remain present and not on your phone and although it may be difficult, do not fall asleep while holding your baby.
There have not been official conclusions regarding the most optimal length of time kangaroo care is practiced to achieve the maximum benefits. But, once you decide to do it, you need to practice it for at least for an hour each time. As long as the infant tolerates kangaroo care, in general, it is usually practiced for 1-3 hours each time. The NICU care team will use their judgement in balancing what is best for the infant coupled with the parent’s availability and preferences.
How to pump while doing kangaroo care
For me, I became frustrated that I had to put William back after 3 hours just so I could pump. So I quickly found a solution that allowed me to pump while doing kangaroo care so I could hold him longer. First and foremost, be prepared. Ensure your pump, cleaning wipes and all of your pumping supplies are near you before you sit down to do kangaroo care. Once it was time to pump, I would gently shift William slightly to one side of my chest, ensure he was stable and I would pump one breast at a time. I would then gently shift him over and pump the other side. Although it is not the most efficient way of pumping, it was worth it just to be able to hold him longer.
Promoting kangaroo care
As NICU care team members, we need to promote and encourage kangaroo care everyday! Nurses specifically play a crucial role in shaping the NICU environment and promoting parent and infant attachment. Rather than making the parent ask if they can do kangaroo care, consider asking the parent each time they visit, “what is your plan for the day? Or what time do you plan on doing kangaroo care?” You will not only take the uncertainty and pressure off of the parents, but actually give them permission to hold their baby – everyday they are available to visit!
By encouraging daily kangaroo care, educating the parents, and being flexible about when kangaroo care is conducted, you are absolutely making a difference in the long-term outcomes for these infants! Believe me, I know as a former NICU nurse the amount of time and resources it takes to get the parents and baby set up for kangaroo care each time. But, as a former NICU parent, I want you to know that what you are doing is making a difference! For NICU parents to be able to hold and bond with their baby, it is changing the course for the family as a whole and for the baby’s long-term neurodevelopmental outcomes!
And as the parent of a NICU baby, when you are visiting your infant, if you have not been told yet about kangaroo care or it has not been offered to you, please ask your nurse or provider about it! Kangaroo care should be promoted and encouraged as long as your infant is stable and fit the criteria.
I created this particular podcast as well as episode 14 to educate you on all of the benefits of kangaroo care, so you are fully informed and aware of just how beneficial it is for your NICU baby! Even if you do not believe me, all of the research proves that it does indeed make a difference! As I previously mentioned, if you have not listened to episode 14, go back to hear all of the benefits kangaroo care will provide your baby, for you as a parent, and for your family as a whole!
Click below to see a simple breakdown of how kangaroo care ultimately improves your baby’s long-term developmental outcomes.
Also, to help build your confidence so you can see how well you’re doing, we put together a log sheet so you can document each time you do kangaroo care with your little one. Document in the log how it made you feel and how your baby responded. It will be a great reminder each day your baby is in the NICU and even after years have passed. You will be amazed at how well your infant begins to adjust and the improvements they continue to make with all of the kangaroo care you are providing!
Closing
Whether you are a NICU parent or a member of the NICU care team, I truly hope this podcast was informative and beneficial. As I mentioned, it was a great reminder even for me to review all of the benefits of kangaroo care and it stirred up so many memories of when William was in the NICU. As I mentioned in episode 14, there were so many factors that contributed to William’s success during his NICU journey and beyond, but I know for a fact that our daily kangaroo care was a huge component to his health then and ultimately his long-term outcomes today.
If you work in a NICU that does not effectively promote kangaroo care, I strongly encourage you to take some of my suggestions and find supportive research to build it up in your NICU. Develop a multidisciplinary team with parental involvement to improve your rates of daily kangaroo care. Educate the care team on all of the benefits and why it should be encouraged everyday!
And for parents, remember, you are the most essential member of your baby’s care team, take the knowledge you have gained and do not be afraid to ask about kangaroo care! I promise that once you get your sweet little one on your chest each time, you will not regret it!
As always, share our podcast or this particular episode with someone who you feel would benefit from it.
Remember, once empowered with knowledge, you have the ability to change the course.
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