Vol. 21 Issue 23
NICU staff borrow a trick from nature to help infants keep warm and bond with parents
What do kangaroos and neonatal intensive care units have in common? At first, you may think, "Not much."
A kangaroo carries her prematurely born "joey" in a warm pouch nestled in the front of her body and she does this for up to 9 months. Kangaroo care in NICUs imitates this marsupial habit.
Just as it sounds, kangaroo care is the practice of taking a premature infant out of his heated incubator to be held skin-to-skin by his mother and sometimes father. The diaper-clad infant is placed vertically upright, chest to chest, between his mother's breasts and covered. Kangaroo care provides physiologic benefits to the infant and has been shown to improve parental-infant bonding.
Power of the Pouch
Kangarooing is effective in keeping babies warm as well as creating a bond between parent and child which may be hindered by an incubator and tubing.
Preemies, especially those weighing less than 1,000 grams, get cold very quickly. The only way for these infants to stay warm is to be kept in a very warm environment, like an incubator, regulated through the use of a sensor placed on the infant's skin.
A premature infant's skin is very thin and does not have much subcutaneous fat to maintain his body temperature. When infants get cold they metabolize brown fat to warm themselves, leading to metabolic acidosis which already is a concern with the population.
The air temperature in their incubators ranges between 95-100º F, in the first week after birth much hotter than the ambient air temperature in the NICU, which is about 68º F.
When a pregnancy ends in pre-term delivery, the mother often feels a large burden of responsibility for her infant's early birth. The dynamics of this situation and the changing hormones after delivery can set the mother up for emotional upheaval. The range of emotions she experiences is very complicated, and not being able to bond with her baby makes the situation worse.1
Initial feelings run the gamut of excitement, amazement, fear, guilt, worry, anxiety, detachment and even awe, all within a few days. The connection parents felt with the child in the womb is gone; they do not feel they can protect their infant from the outside world. Thus, it is important that NICU staff foster attachment early on between the parents and the infant, another reason for kangaroo care.2
Kangaroo care began in Bogata, Colombia, as an alternative to incubator care.3 It evolved out of necessity in the early 1980s because the mortality rate for pre-term infants in Bogata had reached 70 percent. From concern for their babies, mothers started holding their premature infants 24 hours a day and slept with them tucked beneath their clothing simulating a kangaroo's pouch.
Health care providers realized that kangaroo care resulted in a precipitous drop in neonatal mortality. In fact, babies were not only surviving, they were thriving.4 The practice has since expanded to other countries including the United States.
Kangaroo care at Main Line Health System's NICUs has been fairly successful for both infants and parents. The practice isn't for all infants. Some premature babies do not tolerate being handled, can't find a comfortable position while being held and therefore require more oxygen and sometimes become bradycardic.
But for those that do well with kangaroo care, the therapy, offered at all three Main Line hospitals in suburban Philadelphia often begins several days after birth when the mother has recovered and the infant is stable. We wait a few days for the infant's respiratory status to become stable and because umbilical arterial lines, which are usually discontinued a week after birth, can dislodge accidentally.
When the infant and parents meet the above criteria, the infant is held for 45 minutes to 1 hour at a time. Therapy is usually done before a feeding when the infant's stomach is less full to prevent regurgitation. Parents are advised to wear a shirt that buttons down the front, preferably a little big, in order to have the shirt cover both them and the infant against their skin.
Kangarooing starts with the nurse setting up the parent in a comfortable rocking chair with pillows and a footstool. The infant is then prepared by securing all intravenous sites, verifying all monitors and leads are set and secured in place, suctioning the airway if needed and making sure the endotracheal tube is secure. Emergency equipment should also be available at the bedside such as an airway, suction apparatus, oxygen and a resuscitation bag. The skin probe is left in place to monitor the infant's temperature while being held.
With preparation complete, a nurse or respiratory therapist helps transfer the infant and equipment into the parent's arms. When the infant appears to be in a comfortable position on the parent's chest, pre-warmed blankets are used to cover the infant's back and the parent's shirt is wrapped around the infant. Ventilator tubing is taped to the chair to keep it from pulling on the infant's face.
Once infant and mother are comfortable, a privacy screen is set up around them and overhead lights are dimmed. Parents are aware that staff is available and will be checking on them but are given as much privacy as possible.
Parents love kangaroo care. The only drawback mentioned is that the parent holding the infant cannot see the infant's faces, so photographs of their time together are offered.
Studies on kangaroo care have found that its practice is beneficial to both parent and infant. For example, it helps mother's milk production, and infants gain weight, grow faster, have better sleep periods and less apnea.1
References available at www.advanceweb.com/ot or upon request.
Ellen Thomas Logan, BSN, RN,C, has been a NICU nurse at Lankenau Hospital, Wynnewood, PA, for the past 24 years.