The BIG and Positive Impacts of Skin-to-skin Care in the NICU

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Introduction

Happy Thanksgiving Everyone! I hope you all were able to enjoy time and fellowship with your family and loved ones on this holiday! I am also hopeful that despite eating so much turkey with all of that tryptophan, that you do not fall asleep as you are listening! 

One of the many things that I love about the time surrounding Thanksgiving, is that it helps us to pause and have more moments of gratitude allowing us time to reflect on the blessings we have in our lives. I am very blessed and grateful for so many things in my life! I also want to take a moment and thank all of my listeners! I am so grateful for ALL of you! Whether this is your first time joining us or you are a seasoned listener, I am grateful that you are here and so thankful for your support! My wish is that these episodes reach NICU families and clinicians and that they bring value to your personal journey, whatever it may look like. So thank you so much for being here and we hope to continue to bring you insightful, supportive, and educational content! 

If you did not know, November is prematurity awareness month and we just celebrated World Prematurity Day on November 17th!  During this month, we bring more awareness to all of the premature infants born each and every day, as well as the clinicians who care for them and the parents. Despite all of the latest technology and advances in healthcare, one in ten children are born prematurely in the United States. Across all countries, the rate of preterm birth ranged from 4–16% of babies born in 2020. Unfortunately, preterm birth rates have not changed in the last decade in any region of the world. 

And sadly, preterm birth complications are the leading cause of death among children under the age of 5. Infants born prematurely are more likely to have long-term academic difficulties, cognitive impairments, learning disabilities, and/or emotional and behavioral issues that will not only impact their life, but they also have a significant toll on the entire family. Researchers are consistently trying to find strategies to prevent preterm births, but as I just said, the rates have not changed in the past 10 years. So, we as NICU clinicians continue to practice evidence-based care in the NICU to optimize neonatal outcomes. We focus not only on survival of premature infants, but we want them to be healthy, neurologically intact and to have the opportunity to thrive throughout their lifetime.  

As you know if you’ve listened to the podcast before, I continually promote family-based care in the NICU. Research has shown that when parents are more engaged and not only involved in their infant’s daily care, but also in shared decision-making, it improves the infant’s long-term trajectory! A consistent and crucial component of family-centered care or family-integrated care, is the practice of skin-to-skin care otherwise known as kangaroo care. This year, the theme for Prematurity Awareness Day was Small Actions, BIG IMPACT: Immediate Skin-to-Skin Care for Every Baby, Everywhere. And, I could not agree more! The small action of assisting parents with immediate skin-to-skin care has a very BIG IMPACT! Obviously, every clinical situation is different, but when possible, infants should be skin-to-skin with their parents. We have to work towards providing immediate and consistent skin-to-skin care in the NICU. If we are unable to provide skin-to-skin care immediately due to the infant’s clinical condition, we, as a united clinical team, must try, everyday thereafter, and as soon as possible, to provide skin-to-skin care for the infant and parents. The benefits for the infant and parents are endless! Together we truly can make a difference in the lives of the infants and parents!

Research continues to show the benefits of kangaroo care, which is why it continues to be a core component of evidenced-based care in the NICU! So get ready to become empowered as we review the benefits of Kangaroo care in the NICU!   

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The BIG and Positive Impacts of Skin-to-skin Care in the NICU

 

What is Kangaroo Care?

Skin-to-skin care refers to a method of holding an infant in an upright and prone position, skin-to-skin on the parent’s chest for a period of time. The infant will only have a hat and diaper in place and the parent will also have bare skin. 

The benefits of kangaroo care are endless and not just for the baby! Kangaroo care has shown benefits for homeostasis for preterm infants including maintaining a healthy body temperature and increased cardiorespiratory stabilization. Additionally, kangaroo care is associated with decreased likelihood of infection, severe illness, and death.

A recent study showed that even a very small amount of kangaroo care as minimal as 1 hour a day for 14 days with preterm infants compared to infants who remained in an isolette, was associated with improved fetal and maternal outcomes 10 years later. This was a breakthrough study since it was the first to demonstrate the long-lasting value of early kangaroo care. 

Skin-to-skin care is supported by the World Health Organization (WHO), Baby Friendly Hospital Initiative (BFHI), the Academy of Breastfeeding Medicine (ABM), and American Academy of Pediatrics (AAP). It is also an extremely important component of family-centered care. 

World Health Organization – Recommendations for Care of the Preterm and Low Birthweight Infant

The World Health Organization (WHO) leads global efforts to promote healthier lives through all stages of life. They released updated recommendations for care of the preterm and low birthweight infant last November. The guidelines developed by the WHO are meant to help end-users or clinicians make informed decisions on whether, when, and how to undertake specific actions such as clinical interventions, diagnostic tests, or public health measures with the aim to achieve the best possible individual or collective health outcomes.

The guidelines include preventive and promotive care, care of complications and  family involvement and support. Under preventive and promotive care is Any Kangaroo Mother Care which was updated in the guidelines. Kangaroo mother care is recommended as routine care for all preterm or low-birthweight infants. Kangaroo mother care can be initiated in the health-care facility or at home and should be given for 8-24 hours per day or as many hours as possible. This particular guideline is labeled as a strong recommendation with a high-certainty of evidence. Additionally, the WHO organization followed Any Kangaroo Mother Care with a new recommendation, Kangaroo Mother Care (KMC) for preterm or low-birthweight infants should be started as soon as possible after birth.  

Kangaroo Care with our son

As a NICU nurse and now as a NNP, I thought that I understood the importance of kangaroo care and I always tried to promote it. But, after I had my son prematurely, I realized that I never truly appreciated the importance of kangaroo care for the baby and the family as a whole! I know my daily kangaroo care sessions with our son were one of the integral pieces that contributed to his success!

After having our son William, at 23 4/7 weeks, we held off on holding him due to intraventricular hemorrhage prevention. But, on his 5th day of life, I was able to put our sweet boy to my chest for the first time! It was unforgettable!

On the next day, I taught my husband to do the standing transfer and he held him for the first time. Essentially everyday thereafter, one or both of us did kangaroo care for 1-6 hours a day total. I would read to him, sing to him, pray with him or just sit quietly with him.

While William was still in the NICU, we had several physicians and nurses comment on William’s quiet-alert states and how interactive he was despite being born so prematurely. William loved kangaroo care and I cannot even begin to describe the fulfillment it brought to me as his mother!

History of Kangaroo Care

Kangaroo care was initially described in Sweden in 1976 as “early contact” with the mother and baby at birth. But, it became especially popular in Colombia out of necessity as an alternative method of caring for low-birthweight infants in resource-limited countries. In 1978, the Neonatologist, Dr. Sanabria used the method to care for low birthweight infants where there was a lack of equipment to keep babies warm. In under-resourced settings, neonatal mortality and infection rates were high due to overcrowded nurseries and inadequate staffing. In the original version of kangaroo care, infants were placed in continuous skin-to-skin contact for 24 hours a day with frequent and exclusive breastfeeding. Researchers found a reduced rate of infant mortality – so not only did more babies survive, but they actually thrived!  

So how did this translate into our practice of kangaroo care today? With our modern day practices, intermittent skin-to-skin care has been modified from the original version of kangaroo mother care. It has now been adopted in resource-rich countries for healthy, term infants as well as those who require neonatal intensive care, including those who require ventilatory support and/or are extremely premature. 

Benefits Kangaroo Care for the Infant

Increased Breastmilk Production

Evidence has shown that the most substantial benefit of skin-to-skin care is the significant improvement in milk production. The increased volume then results in a longer duration of breastfeeding. Several breastfeeding measures have been reviewed including initiation, exclusivity, performance, success, duration, and milk production and they have ALL shown benefits from kangaroo care.

More kangaroo care infants are breastfeeding at discharge and beyond at 1, 2, 5, and 6 months than non-kangaroo care infants. The Baby Friendly Hospital Initiative is an international set of guidelines to promote, protect, and support breastfeeding. Within the initiative, kangaroo care is one of the “ten steps to successful breastfeeding.” Although they were initially developed for healthy, term infants, a group of experts made recommendations to adapt the “ten steps” to ill and preterm infants who require intensive care. The provision of early, continuous, and prolonged kangaroo care without unjustified restrictions is cited as crucial to improving breastfeeding outcomes in this vulnerable population. 

With the improvements in milk production and longer duration of breastfeeding, it allows the infant to receive more of the mother’s milk! There are many benefits to infants receiving breastmilk, but it is even more crucial for preterm infants to receive breastmilk. Breastmilk decreases the incidence of infections and necrotizing entercolitis (NEC) – an acquired neonatal disorder caused by a combination of mucosal injury, hypoxia, and infection of the intestinal wall. Breastmilk also improves brain and overall growth and ultimately neurodevelopmental outcomes. 

Maintains infant’s temperature

And just as the original intentions of kangaroo mother care, infant warming during skin-to-skin care has been confirmed by meta-analyses. Skin-to-skin care helps to maintain the temperature of extremely low birthweight infants. The mother’s breasts themselves have been shown to change in temperature to match the baby’s temperature needs – isn’t that amazing!?! Since the baby’s temperature can be regulated while skin-to-skin, it allows parents to hold and bond with their baby early on even when they are so small. 

Improves Homeostasis

Additionally for the baby, kangaroo care can stabilize the baby’s other vital signs. Kangaroo care will help to stabilize their heart rate and improve their breathing pattern. As a provider at a delivery of a late preterm or term infant I always encourage the nurses to place the infant skin-to-skin with their mother if possible. It oftentimes will help to regulate their breathing and assist with their transition. That way, the baby can stay with the parents where he or she belongs as opposed to a forced unnatural separation from the parents.  

Skin-to-skin care has also been shown in some studies to minimize the frequency of desaturations when compared to swaddled holding. Initially, especially with infants who are ventilated, it may take a few minutes for the infant and their oxygen saturations to stabilize and level-out after the transition from their isolette to their parent’s chest, but once they are settled, kangaroo care has been shown to be very beneficial for stabilizing oxygen saturations. 

One day, our son William was experiencing more apnea and desaturations than usual. My husband and I were sitting outside of his isolette feeling utterly helpless. We had not been able to do skin-to-skin care with him that day. Although it was unusual for William’s care team, that particular day we were discouraged from doing skin-to-skin care since he was having a rough day with so many episodes. So we continued to just sit there – until my husband stood up and said, “forget it! I’m going to hold him.” Although our nurse was hesitant, she assisted in getting William out and onto my husband’s chest….and within minutes, the amount of apnea and desaturations he was experiencing dramatically improved.

Stabilize Physiologic Functions

When infants are born prematurely, there is a disruption in the baby’s neurobehavioral development that results in an immature and disorganized nervous system. If stressed, preterm infants display specific signs including but not limited to yawning, sneezing, a change in vital signs, finger splaying, color changes, hypotonia or hyperextension of extremities. But, kangaroo care practiced 5 or more times per week for at least 30 minutes at a time has show improvement. These babies have shown increased alertness and attention to the environment when they were tested at post-menstrual ages of 37 weeks, 40 weeks, 6 months, and 12 months. Kangaroo care infants also have higher mental and motor developmental scores than non-kangaroo care infants at 6 months and 1 year. These findings coupled with other evaluations, concluded that kangaroo care accelerates autonomic and neurobehavioral development. 

Research has also shown that infants who receive regular kangaroo care have more mature and improved sleep organization with longer periods of quiet sleep and alert wakefulness and an improvement in sleep cycles as well as a decrease in arousals from sleep. What does all of this mean? It means that infants who receive kangaroo care on a regular basis develop a more rapid improvement in state organization resulting in more alert and responsive behavior and less irritability and fussiness.  

Increased Development Infant’s Microbiome

Additionally, kangaroo care has the potential to contribute to the development of an infant’s microbiome, which has potentially life-long effects. The microbiome is the colonization of the surfaces on the body including the skin and gastrointestinal tract and they play an important role for the immune system. When an infant does regular kangaroo care, they are exposed to their parent’s skin microbes which help colonize the infant with healthier microbiomes than they would have otherwise not been exposed to. But, the most amazing part is that the mother is also exposed to the infant’s microbes and her immune system produces an immune response to the microbes and will share those immune properties with the infant through her breast milk! Totally amazing – right?

Reduced Stress and Minimize Pain Perception

I know as a NICU mother one of the most anguishing parts of William’s time in the NICU, was helplessly watching the stress and pain he endured on a daily basis, especially in the initial weeks. I would have done just about anything to have been able to minimize it for him. Research suggests that NICU infants experience around 10 painful procedures each day. Isn’t that heartbreaking! And in response to the stress, the infant’s body diverts resources away from growth but rather toward meeting the immediate needs and demands of the body.

Although significant progress has been made over the years in NICUs to provide more developmentally appropriate care and to manage neonatal pain better, we still have a lot of work to do. We also know that there are profound effects, both short and long term, due to the stress. We must find ways to reduce and attempt to promote positive, stress-reducing experiences.

Skin-to-skin care has been found to be an effective and safe intervention during a painful procedure. Consider having the nurse draw labs while doing skin-to-skin care. Research has shown that when infants experience a reduced state of stress, they are able to better engage with their parents which facilitates bonding. Additionally, they are better able to feed and their gastrointestinal tract will better support digestion, restoration growth, and better long-term developmental outcomes. 

Common emotions and struggles for NICU Parents

NICU parents experience a wide range of emotions, but the majority of them are not the joyful ones they had anticipated. The initial moments that follow the delivery when you envisioned your baby being placed on your chest are now replaced with apprehension as you watch your baby being whisked off to the NICU. Most parents are completely unprepared for either a preterm delivery or for their baby to be admitted to the NICU. All of the feelings of joy parents initially anticipated are now replaced with fear and uncertainty. Many of these feelings are so strong that as a parent, they paralyze you.

Mothers feel powerless. With their feelings of guilt, they begin to feel inferior in their ability to care for their own baby compared to the NICU care team. With such strong feelings of inadequacy, mothers often retreat even more into their self-doubt and overwhelm. Yes, we as part of the NICU care team are the experts, but these are the baby’s parents! We must remind ourselves of this each and every single day. How can we promote attachment, bonding, and confidence in our NICU parents? More skin-to-skin care! 

Being the parent of a critically ill neonate is extremely stressful. NICU parents have a high rate of posttraumatic stress disorder, depression, and additional strains on their family. Skin-to-skin care helps to alleviate some of the common long-term negative outcomes. It helps fathers, especially, feel more included in their baby’s care. Mothers have also reported less stress and more satisfaction with the NICU care and both parents are more responsive to their infant’s cues. 

For me personally, it gave me a purpose each and every day. I looked forward to it and I knew that it was benefiting our son in that moment and also in his long-term development.  

Maternal Attachment

Within the species of mammals, direct skin-to-skin contact between the newborn and mother is critical to support the survival of the newborn through thermal regulation, milk let-down, and bonding. This response to skin-to-skin is evident throughout infancy, but there is believed to be a specific time in the first 2 hours of life when kangaroo care activates neuroendocrine hormonal changes that have long-lasting effects. The key hormone involved in this response is oxytocin or the love attachment hormone! 

Attachment is defined as the emotional connection that is formed between infants and their parents. Studies have shown that mothers who did kangaroo care with their infants had greater mother-infant attachment scores across the post-partum period and improved responsiveness and reciprocity at 10 years. Maternal stress scores have also been found to be lower. 

Benefits Kangaroo Care for the Parents

Skin-to-skin care promotes participation of both parents in caring for the infant. It strengthens the family role in caring for a fragile infant and decreases the common feelings of helplessness. That is huge! Kangaroo care actually helps parents feel like parents!

Research has also shown that mothers and fathers in a skin-to-skin care rich-environment were found to be more sensitive, less intrusive, had more affectionate touch of their infant and spouse, and the family style was overall more cohesive. And most importantly, kangaroo care helps the parents become more comfortable with their infant and more confident! It actually allows parents to nurture and care for their fragile infant. 

Mothers had greater confidence and competence about their nurturing abilities. They report feeling as though they know their infant and experience a more noticeable sense of their role as a mother. Fathers have reported to feel an intense connection and attachment to their infant, feel more involved, experience less anxious feelings, and more confident about their parental role. Fathers have also demonstrated more sensitivity to their infant’s cues and ultimately a better home environment months down the road. The more positive interactions and better attachment counteracts the negative long-term effects of hospitalization on preterm infants’ neurobehavioral development. 

Afterall, we as part of the NICU care team not only want to save infants, but we want to send them home to parents who are healthy, engaged, and confident in their parental role. Even as I researched in preparation for this podcast, it reminded me and became very evident that the benefits for the baby and the parents also positively affect the baby’s long-term developmental outcomes. Whether it’s the decreased risk of infection, their improved sleep organization, better parental engagement, confidence and even stronger parental-child bonds, the long-term effect is improved neurodevelopmental outcomes. So, if you are not doing so already, start doing daily kangaroo care with your little one. If they are not stable enough to yet, ask the nurse and NICU providers each and every day if today might be the day! It will make a difference. 

To see a visual breakdown of all of the aforementioned benefits of kangaroo care for babies and their parents with the common beneficial long-term outcome of improved neurodevelopmental outcomes grab your free kangaroo care graph.

Additional Links for Skin-to-skin Care

Have you been encouraged by this episode and want to learn how to better address some of the common barriers for skin-to-skin care as well as how to assess for infant readiness? You can find all of the information plus tips on how to safely transfer the infant onto the parents chest for kangaroo care, by listening to episode 15.

And, if you are still a skeptic, or would like to learn more about the evidence supported by research to encourage your NICU staff, you must listen to Episode 30: The Positive Effects of Kangaroo Care: A Literature Review where I do just that, review literature and evidence on the proven positive effects of kangaroo care.

Closing

I hope you gained a new piece of knowledge on all of the benefits of skin-to-skin care! As I mentioned, kangaroo care should be a key component of the care we provide in the NICU – just like administering a medication, it is considered a treatment! And not only does it improve the outcomes for the infant, but the parents as well! It truly assists with bonding, feelings of attachment, connection, love, confidence, and it helps to improve breastmilk supply in mothers.

I completely acknowledge that logistically, it does take time, organization, and involves coordination of several members of the care team. I also understand that it may leave caregivers with feelings of uncertainty because of the risk of dislodging critical lines and tubes on the baby, but the benefits outweigh the risks! Once it is practiced repetitively and becomes part of your daily routine, your confidence will increase and it will continue to go smoother, not only for you as a caregiver, but also the parents as well!

The standing transfer method eases the transition for the infant from the isolette to their parent’s chest and it allows the parent to safely secure the infant to their chest prior to sitting while the NICU care team members monitor the lines and tubes. Go HERE to see a video of the standing transfer method.

For my parents who are listening, I encourage you to ask your baby’s NICU care team each and every day if you can hold your infant skin-to-skin. As I mentioned, the practice should be done daily, but your infant may be too critical at this point, or sadly, your infant may be in a unit that does not routinely offer or practice daily skin-to-skin care. Despite this, I encourage you to ask each day and it will encourage the NICU care team to help get your baby out so you can hold them skin-to-skin. By doing so, they will know that it is part of your daily routine! Do not be afraid, remember, this is YOUR baby and it will be so beneficial for both of you! We’ve got this! Together as a team, we can make a huge difference!

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Remember, once empowered with knowledge, you have the ability to change the course.