skin-to-skin holding (kangaroo care) · • holding skin -to-skin and breastfeeding increase levels...

Skin-to-Skin Holding (Kangaroo Care)

The power of skin-to-skin care for newborns, parents

and families

March of Dimes Mission

Fund Researchto understand the

problem and discover answers.

To improve the health of babies by preventing birth defects, premature birth and infant mortality.

Help Momshave full-term

pregnancies and healthy babies.

Support Familiescomforting them when their baby needs help to survive and thrive.

2

Parenthood begins with that first touch.

Presenter

Presentation Notes

Raise your hand if you think skin-to-skin holding is important. Why? (Gather some positive responses.) Do you view skin-to-skin holding as a nice occasional, sporadic thing to do on a slow day, or do you view it as a standard daily care procedure to incorporate in your plan of care for your patient every day, whenever possible, even on busy days?

Did you know…

…According to some NICU parents, the first time they considered themselves real parents was the first time a nurse encouraged them to hold their baby skin-to-skin?

How soon canwe encouragethis bonding

activity betweenbaby and parent?

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Presentation Notes

Studies have found skin-to-skin holding increases intimacy and attachment between baby and parent. Skin-to-skin holding was found to help a parent feel connected. Eye contact led to an experience of “knowing” infant. In a national evaluation of March of Dimes NICU Family Support, published in the December 2007 issue of Journal of Perinatology (Cooper,et al., 2007) NICU Parents, when asked what brought the highest levels of comfort and parenting confidence to parents, they voted overwhelmingly for “holding my baby.” When do you start to encourage skin-to-skin holding? (Start a discussion) How do you inform / teach NICU parents about KC?

What are some obstacles stopping you from suggesting

skin-to-skin holding to a parent?

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Presentation Notes

What stops you from suggesting skin-to-skin holding? (Looking for… too sick, too small, etc.) What challenges do you face when you consider offering skin-to-skin? Are there obstacles that would make it something you would not do? What stops staff from making this readily available? (Discuss cultural, age, gender, biases that might be present before moving on to next slide.)

Common obstacles• Inconsistent criteria/standards • Difficulty assessing newborn readiness • Staff concern about adverse events (extubation, etc.)• Lack of knowledge about depth of benefits• Staff concern about workload, time, space, multiple staff needed

(Engler et al., 2002)

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Presentation Notes

Before the first click, ask: “What are some obstacles you face when considering offering skin-to-skin holding with a parent?” Wait for answers and then click mouse for answers. (Other factors besides those on the slide might include: age of parent; age of infant, perhaps too small and fragile, or perhaps too old and already in a big bed and wearing clothes; parent’s religious background; parent’s body odor or lack of cleanliness)

Kangaroo care enables moms to regain the temporarily lost

relationship with their child, and enables fathers to experience the beginning of a new relationship.

(Fegran et al., 2008)

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Presentation Notes

According to the article titled “A comparison of mother’s and fathers’ experiences of the attachment process in a neonatal intensive care unit,” parents experience the bonding process uniquely. Mothers begin the bonding process as soon as they discover they are pregnant. (Nesting, talking to baby, rubbing belly, etc.) When the baby is born prematurely, she experiences a “loss” of her pregnancy, and many times emotionally separates herself from the bonding/attachment process as a form of protecting herself from anticipated hurt. She has to reestablish her relationship with her baby. The duration of time varies with each case. Fathers typically don’t experience a bond or attachment until after the baby is born. They are starting a new relationship at the exact same time the mother is detaching from a formed relationship. They are in two separate places.

“If a baby can be transferred to a scale for weighing, a baby can be transferred to a parent for skin-to-skin holding.”

Robert White, M.D., Neonatologist Pediatrix Medical Group Memorial Hospital, South Bend, Indiana

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Presentation Notes

What kind of messages do you provide (if you are NICU management or Neonatologists) or receive (if you are a nurse) about making skin-to-skin holding as much of a daily care priority as something like a daily weight?

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What is skin-to-skin holding?• A holding technique, skin-to-skin, chest-to-chest, in an upright

position where the baby is only wearing a diaper on the parent’s bare chest (Ludington-Hoe et al., 1998)

• A non-invasive, supportive, and natural early intervention for preterm infants (Dombrowski et al., 2000)

• It’s also known as “kangaroo care” and has been the subject of more than 263 studies.

A mother in Nebraska enjoying a special skin-to-skin moment with her daughter, Ava.

Who thinks skin-to-skin holding is important?

• March of Dimes (2001-current) promotes skin-to-skin holding in its educational literature, program materials and throughout the NICU Family Support® program.

• World Health Organization (WHO, 2003) Kangaroo Mother Care: A Practical Guide.

• American Academy of Pediatrics (AAP, 2005) A Sample Hospital Breastfeeding Policy for Newborns. Cites the benefits of skin-to-skin holding on milk letdown and parental bonding.

• National Association of Neonatal Nurses.Transfer Procedure for Ventilated Kangaroo Care (NANN, 2008) at www.nann.org.

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Presentation Notes

Skin-to-skin holding is endorsed by many professional organizations that have published articles, guides, protocols and techniques.

http://www.nann.org/�

Selected, proven benefits to baby: apnea, brady, O2 sat, heart rate

• Four-fold decrease in apnea; mechanically ventilated babies able to tolerate transfer and position changes without increased oxygen requirements. (Cleary et al., 1997; Hunt, 2008)

• Holding skin-to-skin did not increase bradycardia episodes. (Gale, Vandenberg, 1998)

• Heart rate was more regular for infants held skin-to-skin. (Aucott et al., 2002)

• Kangaroo care has proven successful in improving survival rates of premature and low birth weight newborns and in lowering the risks of nosocomial infection (Conde-Agudelo, Diaz-Rossello, & Belizan, 2003).

Presenter

Presentation Notes

Before the first click, ask: “Let’s look at how skin-to-skin holding benefits the baby. How many benefits to baby can we brainstorm?” Wait for answers, or write them down, and then click to find out answers.

Selected, proven benefits to baby: body temperature and lactation• Thermal synchrony between mothers and their babies was shown.

(Ludington-Hoe et al., 2006)

• Mothers increased their milk volume, doubled rates of successful breastfeeding and increased duration of breastfeeding with skin-to-skin holding. (Mohrbacher & Stock, 2003)

• Physiologically a mother’s breasts respond to her infant’s thermal needs. (Ludington-Hoe et al., 2006)

• Babies held skin-to-skin had fewer breastfeeding difficulties. (Tessier et al., 2003)

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Presentation Notes

Proponents of kangaroo care encourage maintaining skin-to-skin contact method for about six weeks so that both baby and mother are established in breastfeeding and have achieved physiological recovery from the birth process. (Mohrbacher & Stock, 2003; London, et al., 2006)

Selected, proven benefits to baby:sleep, memory, neurodevelopment

• Enhanced neurological development was shown. (Ferber, Makhoul, 2004)

• Babies spent more time in sleep; shown as necessary for neurosensory development, preservation of brain plasticity, learning and long-term memory. (Graven, 2008)

• Skin-to-skin holding increased the maturation rate of circadian system; secondary to favorable oscillation between quiet sleep and wakefulness. (Feldman et al., 2002)

• Skin-to-skin holding accelerated autonomic maturation, as shown by greater gains in vagal tone. (Feldman et al., 2003)

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Presentation Notes

If you could give the baby a pill that would accomplish all these things, would you? If yes, let’s talk about that. Do you think you might be more apt to incorporate a medication into your plan of care for the day, instead of incorporating a skin-to-skin session for your baby every day?

• Holding skin-to-skin and breastfeeding increase levels of oxytocin in mothers, enhancing attachment to their infant and their sense of motherhood. (Ferber, Markhoul, 2004; Morrison, 2006)

• Holding skin-to-skin improved bonding and attachment in babies of teen parents. (Wang YH, Kuo HH, 2006)

• Increased confidence in parenting skills was shown with skin-to-skin holding. (Charpak et al., 2005)

• Skin-to-skin holding increased sense of control in parents. (VandenBerg, 2000)

Benefits to mom & dad:bonding, attachment, confidence

Presenter

Presentation Notes

Before the first click, say: “Not all of the benefits are for the infant. Parents benefit from holding skin-to-skin as well. Let’s brainstorm some benefits to mom and dad.” Wait for answers before revealing answers. Resilience and feelings of confidence, competence, and satisfaction regarding baby care (Tessier et al., 1998; Conde-Agudelo et al., 2003; Kirsten et al., 2001; Charpak et al., 2005). •A hormone called oxytocin is released when your baby nurses, which prevents postpartum hemorrhage and promotes uterine involution (the return to a non-pregnant state). Mothers who breast-feed continue to receive oxytocin whenever they nurse. This oxytocin is naturally produced and released by their own bodies in response to nursing. Mothers who bottle-feed only receive oxytocin immediately after the placenta is delivered, usually through an injection or in their IV.

Benefits to mom & dad:parental comfort and healing

• “Skin-to-skin holding may lessen maternal depression.” (De Alencar et al., 2009)

• Skin-to-skin holding promotes a sensory dialogue between parents and infants. (Gayle & VandenBerg, 1998)

• Holding skin-to-skin reduced postpartum depression and anxiety symptoms. (Anderson et al., 2003)

• A reduction in father’s fears of “breaking baby” was shown with skin-to-skin holding. (Bauer et al., 1996)

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Presentation Notes

When you talk to graduate NICU parents, what do they tell you are their good memories of their NICU experience? A study by Feldman, et al investigated the effects of early separation on behavioral regulation in mothers of preterm infants, who had necessarily been separated from some or all of the birth and care giving experiences for their infants. When comparing these mothers to those of term baby mothers, attachment behaviors and mental representations of their baby, necessary in early relationship development, decreased as the duration of separation from their infant increased. Thus, the importance of early mother-premature infant proximity is essential not only for physiologic and behavioral organization in the neonatal period but also for later mental health outcomes (Feldman et al., 1999).

Benefits to mom & dad:bereavement and palliative care

• Palliative care embraces the baby as a whole, taking into consideration physical, emotional, spiritual and social needs, along with the needs of the family.

• Offer the option of skin-to-skin holding and photography with a family whose baby is dying. Invite the whole family to participate. These may be the only family photographs they receive.

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Presentation Notes

MEMORIES FROM HEATHER: “My first child, whom I joyfully anticipated and for whom I had so many lovely dreams, arrived very unexpectedly at 24 weeks gestation. All the best care, machines, and drugs were ineffective at helping him breathe or fight off infection. His condition progressively deteriorated, and he died at 20 days. Every day that I walked through the NICU to get to his bedside, I watched other families Kangaroo Caring their babies, saw the happy looks on their faces, and hoped I too would someday get to do that with my son. Instead, my son’s condition worsened every day, more and more wires and tubes were attached to him, and he was never stable enough to get out of the bed to be held. On the night he died, I sensed he was going to leave us that night, and so I wore a specific button-down shirt to the hospital in the secret hopes that I could Kangaroo Care my son at least one time. That night, as the vigil by our son’s crib wore on and he struggled, I asked the doctor if I could Kangaroo Care, but she said no and that we should wait. Questions in my mind that I did not verbalize were: “Why not?” And “Wait for what????” Later that evening it was clear he was not going to survive and we made the heart wrenching decision to say our final goodbyes. Then they said they would take him out of his bed and let me hold him. I was overwhelmed with opposite emotions; great joy that I was finally getting to hold my precious son, and pure grief that this was to be the first, last, and only time I would ever hold him. I thought to myself then that I wanted to hold him as close to my heart as possible and never forget how his warm tiny body felt next to mine and I thought again about asking to Kangaroo Care, but I kept silent. I was totally overwhelmed, and totally inexperienced in being with a dying child. I relied on the health care professionals to lead me and tell me how you do this. When they wrapped him up in blankets, and let me hold him, his saturations went up for a while -- the best they had ever been since our start in the NICU. I didn’t want to disrupt him. He was finally happy and we were finally bonding as mother and child. He died peacefully in my arms. The memory of that night will always bring mixed emotions for me. There will always be deep pain knowing that my child suffered and died, that I never got the chance to know him, and that the only time I held my son was as he died. But the memory of that night has also brought me peace as I recall how he seemed to be so comforted as I held him. I know he passed in peace and comfort as he was held by his parents. I think maybe the peace and comfort we all (mother, father, and child) felt would have been heightened if we had Kangaroo Cared – if we had had the chance to do what every parent craves to do with their beloved child – embrace them as warmly as humanly possible: heart to heart. I would have loved to have had that memory to hold on to in my grief. My grief at the loss of my son will go on for ever, and I have so little “good memories” to hold on to. We had absolutely wonderful, compassionate nurses and doctors who helped us through the situation so much. But, I wish the doctors and nurses would have allowed me to have that good memory. Maybe the peaceful feelings I do have about that night would have been heightened if I, as his loving, adoring mother, would have had the opportunity to hold him as close as I possibly could have.”

Infants who are not ready• Any clinically unstable infant • Infant with a chest tube• Post-op surgical infant• Infant who would experience intense pain from being transferred

(Osteogenesis Imperfecta diagnosis, etc.)• Exceptions can be made on a case-by-case basis, with a physician’s

order.

Presenter

Presentation Notes

Before the first click, ask: “Are all babies ready for skin-to-skin holding? When is a baby not ready?” Wait for answers before clicking. If your hospital has a skin-to-skin protocol, staff should refer to it.

If infants are not ready for skin-to-skin holding, encourage the following:• Gentle, still touch• Hand swaddling (hand hugs)• Breast pumping• Reading at the bedside

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Presentation Notes

Gentle, still touch is very important, even for the most sick and fragile of babies. Reassure the parent that the infant knows his/her voice and smell, and will be comforted when these things are accompanied with their gentle touch. Remind them not to stroke their baby, even though that feels like a natural thing to do. Stroking is often too much stimulation for babies in the NICU. Many times, they are not quite ready for all the stimulation of life outside the womb. Gentle, still touch is best for little ones. Hand Swaddling (Hand Hugs) can be performed on very sick and fragile babies too, especially those not yet ready for skin-to-skin holding. Place very light pressure on the baby’s head with one hand and cup their feet gently with the other hand. This can sometimes calm a fussy baby. Parents benefit from hand swaddling because they can feel their baby breathe and see him/her calmed by their touch.

How can we improve our practice?• Develop guidelines.• Develop teaching plan for

family.• Develop ongoing teaching

plan for staff.• Develop teaching plan for

mothers on the antepartum unit before NICU admission.

• Continue to encourage skin-to-skin holding even after a baby graduates to wearing clothes.

• Encourage families to hold skin-to-skin at home after discharge.

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Presentation Notes

Does your hospital have a Kangaroo Care committee? Does it have signage/photography up promoting it? Does it have doctors promoting it? Is your unit conducive to the privacy needed for skin-to-skin holding?

Enhancing the skin-to-skin experience

privacy screenhand held mirrorstanding mirrorzero gravity chair

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Presentation Notes

Hand mirror: provides the chance for parent to view their baby without compromising proper positioning. Privacy screen: Some screens are more stable than others. Try to use one with sturdy feet, rather than a tri-fold metal frame, which might fall if bumped into. Standing mirror: Typically used in labor and delivery, this mirror by Hill-Rom® is a perfect tool to use for parents holding their infant skin-to-skin. It rolls right next to the chair and the mirror can adjust for hand’s-free viewing of baby. Recliner: A zero gravity chair is recommended as a low-cost, space-efficient, comfortable way to encourage parents to hold their infant skin-to- skin for extended periods of time.

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Transfer Procedure for Ventilated Kangaroo Care

wall posterNann.org

Enhancing the transfer process

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Presentation Notes

There are many devices on the market today to assist in kangaroo care transfer safety. This poster from the National Association of Neonatal Nurses describes how to safely transfer a baby on the ventilator for skin-to-skin holding.

What We Say Can Help, Hurt or Heal“Your baby’s heart rate is dropping. It’s time to put her back.”“He looks so peaceful in your arms.”“You’re doing such a great job.”“You are not holding him right. He’s not comfortable.”

Presenter

Presentation Notes

Before the first click, say: “Parents in crisis won’t always hear your message the way it is intended. Often, they feel incompetent and unconfident in their care giving. Your encouragement and reinforcement of how they hold, touch and love their baby speaks volumes! Allow parents to assess the situation, rather than telling them what’s happening.” First Click: What do you think about the first phrase: “Your baby’s heart rate is dropping. It’s time to put her back.” What is the nurse’s intent? (Looking for: baby’s safety, protecting the baby) What do you think the impact on the parent might be if they heard this? (Looking for: feeling like an incompetent parent, maybe I won’t hold the baby next time) Can you phrase this in a better way? (Looking for: How is your baby doing? Do you think baby is comfortable? Can we reposition her? Etc.) Second Click: “He looks so peaceful in your arms.” What is the nurse’s intent? (Looking for: encouragement, giving the parent confidence) What do you think the impact on the parent might be if they heard this? (Looking for: confidence) Would we change this phrase? (Looking for: NO! It’s perfect!) Third Click: “You’re doing a great job” Nurse’s intent? (Looking for: same as the one above) Impact on parent? (Looking for: same as the one above) How would you rephrase? (Looking for: same as the one above) Fourth Click: “You are not holding him right. He’s not comfortable” Intent? (Looking for: baby’s safety, protecting the baby, comforting the baby) Impact? (Looking for: devastation, I’m a bad parent, I’m not going to hold next time because I’m not doing it right, I’m causing my baby to be uncomfortable) Rephrasing? (Looking for: Is he showing us any signs that he’s not comfortable? How is his color? Can we reposition him to make you both more comfortable?)

“I will never forget the first time my newborn was placed on my chest. She was so tiny, so fragile, but she curled right up into me, as if she instinctively knew that’s where she belonged. It was the closest I’d been to her since she’d been inside me. In that moment, I finally felt like a mother. This child was mine. Those moments (when we kangarooed) would fast become my favorite NICU moments. In those moments, nothing else existed but my daughter and me.”

Denise R, NICU mother

March of Dimes NICU Family Support®

March of Dimes Signature ProgramBegan in 2001 as a direct service program – We celebrated our

ten year anniversary in 2011We have a network of 106 NICU Family Support sites nationwide

and we are growing every year in hopes to provide support to families and to help hospitals provide more family focused care. We have a program in every state, DC, and Puerto Rico, with a goal to reach 84,000 families by end of 2011.

Provides information and comfort to NICU families through an on-site family support person, programs, activities and materials

• Providing information and comfort to families during the NICU hospitalization of their newborn, during the transition home, and in the event of a newborn death

• Contributing to NICU staff professional development

• Promoting the philosophy of family-centered care in NICUs

Core Program Goals

Join more than 100 hospitals nationwide and become a member of the

National March of Dimes NICU Family Support Network today!

For more information, pricing or to request an informational webinar with your team,

contact us at:[email protected]

mailto:[email protected]�

March of Dimes Mission

Fund Researchto understand the

problem and discover answers.

To improve the health of babies by preventing birth defects, premature birth and infant mortality.

Help Momshave full-term

pregnancies and healthy babies.

Support Familiescomforting them when their baby needs help to survive and thrive.

27

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Anderson GC, et al. Early skin-to-skin contact for mothers and their healthy newborn infants. Birth 2003; 30(3): 206-7.

Aucott S, Donohue PK, Atkins E, Allen, MC. Neuro-developmental care in the NICU. Mental Retardation and Developmental Disabilities (Research Reviews) 2002; 8: 298-308.

Bauer J, Sontheimer D, Fischer C, Linderkamp O. Metobolic rate and energy balance in very low birth weight infants during kangaroo care holding by their mothers and fathers. J Pediatr 1996; 129(4): 608-11.

Bauer K, Uhrig C, Sperling P. Body temperature and oxygen consumption during skin-to-skin (Kangaroo) care in stable preterm infants weighing less than 1500 grams. J Pediatr 1997; 130(2):240-44.

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Morrison B. Kangaroo care for full-term infants: state of the science. 2006; Retrieved July 2, 2008, from the International Network of Kangaroo Mother Care at http://kangaroo.javeriana.edu.co/encuentros/6encuentro/abstract2.pdf

National Association of Neonatal Nurses.Transfer Procedure for Ventilated Kangaroo Care (NANN, 2008) at www.nann.org.

Tessier R, Cristo MB, Velez S, et al. Kangaroo Mother Care: a method for protecting high-risk low birth weight and premature infants against developmental delay. Infant Behavior and Development 2003; 26: 384-397.

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http://www.med.umich.edu/nicu/pdf/C.3KangarooCare.pdf�

http://www.marchofdimes.com/printablearticles/inthenicu_kangaroocare.html�

http://www.med.umich.edu/nicu/pdf/C.3KangarooCare.pdf�

http://kangaroo.javeriana.edu.co/encuentros/6encuentro/abstract2.pdf�

http://www.nann.org/�

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