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SKIN TO SKIN (Kangaroo Care)
Approved By
Dr. R. Alvaro
Ms. S. McMahon
Effective Date
June 22, 2007
NEONATAL GUIDELINES
Last Revised
Page:
1 of 7
Guideline #:
106
12 November 2014
COVERAGE
To provide skin to skin (STS) contact for infants, with their parents, in order to:
o reduce risk of hypothermia
o facilitate cardiorespiratory stability
o reduce risk of hypoglycemia
o reduce risk of nosocomial infection or sepsis
o promote bonding by decreasing parental and infant stress
o mprove milk supply
o improve breastfeeding latch and duration .
o reduce length of hospital stay
STS is strongly encouraged for all infants. STS holding is particularly important for LBW and late preterm infants, as
thermoregulation is far superior when baby is held skin to skin as compared with wrapped in blankets.
Teach parents about benefits of STS, and ensure they understand safety precautions as outlined below (Response).
APPLICATION
This guideline applies to all infants not critically ill. Respiratory treatments such as oxygen and/or mechanical ventilation
are NOT contraindications to receiving STS. There are no minimum or maximum weight or age requirements for skin to
skin.
Late preterm infants: Facilitate STS immediately after delivery, as it is correlated with better cardio-respiratory
adaptation and stability, and increased blood sugar levels (Moore et al, 2012).
Infants with TTN (transient tachypnea of the newborn: slightly increased respiratory rate): Facilitate STS
immediately after delivery, as it is correlated with better cardio-respiratory adaptation and stability, and increased blood
sugar levels (Moore et al, 2012).
Twins: Facilitate simultaneous STS for twins when parent is ready, ensuring close monitoring of infants.
After Caesarean section: immediate (within minutes) or early (within 1 hour) skin-to-skin contact after Caesarean section
for healthy mothers and their healthy term newborns may improve breastfeeding outcomes, increase bonding and maternal
satisfaction, maintain temperature of newborns, and reduce newborn stress (Stevens et al, 2014).
RESPONSE
1.
Discuss eligibility of infant for STS in Rounds every day. Although an infant has been deemed “eligible”, STS
may not be appropriate at all times; careful assessment of patient condition is needed prior to STS. The decision
for STS is made by bedside nurse. Consult CRN, Charge Nurse or physician for assistance in decision-making as
needed. For infants less than 1 kilogram, discussion and approval from an Attending Physician must be obtained.
Note plans for STS on the kardex.2.
Record baseline vital signs and ventilator parameters if applicable
before beginning skin to skin.
Record these q1h during skin to skin. Close and continued monitoring is required for the most vulnerable infants
i.e. those with immature autonomic regulation and those with a history of frequent bradycardia and/or apneic
episodes.
Anticipated changes to vital signs during STS:
HR decreases; remains in normal range as infant “settles”
FiO2 requirements decrease, especially for intubated infants
SaO2 increases
Apnea/brady: occurred in ~ 13% of STS episodes in infants 24 – 33 weeks gestation age. Tactile
stimulation, nasal prong repositioning, re-positioning of head, mask bagging or increase in FiO2
resolved all instances without need to end STS
Temperature: decreases transiently in the smallest infants immediately after transfer to parent (not likely
clinically relevant). This is followed by a rapid secondary increase in temperature during STS
SBGH Neonatal Guideline Name: SKIN TO SKIN
(KANGAROO CARE)
Policy Number:
106
Page
2 of 7
3.
Place infant supine on a receiving blanket. Assess breath sounds. Wait up to 15 minutes for physiological
adaptation to this handling. Adaptation is defined as all physiological parameters returning to baseline and staying
there for 3 minutes. If adaptation has not occurred in 15 minutes, the infant is probably not stable enough to
receive skin to skin that day.
4.
Following assessment of a critically ill or intubated infant, notify respiratory therapist and physician/ NNP of
plans to do STS. This will facilitate discussion of the availability of these personnel, in the event that immediate
assistance is needed
5
Standing transfer (where parent stands, puts his/her hands under receiving blanket under baby, lifts baby onto
parent’s bare chest then sits down) is preferred over sitting transfer (where nurse moves baby from bed to parent’s
chest), as it is less physiologically and behaviourally disruptive to the infant.
6.
Exposed areas of infant must be covered. A hat and socks are necessary for all babies. All babies receiving skin to
skin must be covered with a blanket.
7.
During skin to skin contact, infant should be positioned prone and head up, with all limbs flexed, on the parent’s
chest. Parent should be in a sitting or semi-sitting (head elevated 30 – 60 °) position, If infant is receiving
cardiorespiratory and oximeter monitoring, continue these during skin to skin. Observe infant’s condition a
minimum of every 10 minutes during skin to skin. Encourage skin to skin ideally for a minimum of 65 minutes if
infant’s condition remains stable.
8.
For ventilated infants: ventilator tubing must be drained periodically. Ensure tubing is positioned so that drainage
is away from the baby.. The tubing may be secured to the parent’s shoulder with Velcro.
9.
Discontinue STS if condition becomes unstable or infant shows signs of over-stimulation.
10 .
Once skin to skin care is well tolerated, breastfeeding is not contraindicated during skin to skin.
11 .
Provide privacy with blankets covering parent and infant during STS . Leave curtains open to allow continuous
observation of infant.
11.
Record vital signs after skin to skin session.
REFERENCES
Becher, J-C., Bhushan, S.S., & Lyon, A.J. (2012). Unexpected collapse in apparently healthy newborns – a prospective
national study of a missing cohort of neonatal deaths and near-death events. Arch Dis Child Fetal Ed 97, F30 –
F34.
Bhutta, Z.A., Das, J.K., Bahl, R., et al. (2014). Can available interventions end preventable deaths in mothers, newborn
babies, and stillbirths, and at what cost? Lancet 384: 347 – 370.
Carbasse, A., Kracher, S., Hausser, M. , et al (2013). Safety and effectiveness of skin-to-skin contact in the NICU to
support neurodevelopment in vulnerable preterm infants. Journal of Perinatal and Neonatal Nursing 27(3), 255 –
262.
Conde-Agudelo, A., Belizan, J. M. & Diaz-Rossello, J. ( 2011). Kangaroo mother care to reduce morbidity and mortality
in low birth weight infants. Cochrane Database System Reviews (3), CD002771.
.
Engmann, C., Wall, S., Darmstadt, G., et al;. (2013). Consensus on kangaroo mother care acceleration; Lancet 382: e26 –
e27.
Feldman, R., Rosenthal, Z., & Eidelman, A.I. (2014). Maternal-preterm skin-to-skin contact enhances child physiologic
organization and cognitive control across the first 10 years of life. Biol Psychiatry 75: 56 – 64.
SBGH Neonatal Guideline Name: SKIN TO SKIN
(KANGAROO CARE)
Policy Number:
106
Page
3 of 7
Herlenius, E. & Kuhn, P. (2013). Sudden unexpected postnatal collapse of newborn infants: a review of cases, definitions,
risks and preventive measures. Tranl Stroke Res 4, 236 – 247.
Lawn, J.E., Mwansa-Kambafwile, J., Horta, B.L. et al. (2010). Kangaroo mother care to prevent neonatal deaths due to
preterm birth complications. International Journal of Epidemiology 39: i144 – i154.
Lyngstad, L.T., Tandberg, B.S., Storm, H., et al. (2014). Does skin-to-skin contact reduce stress during diaper change in
preterm infants? Early Human Development 90: 169 – 172.
Sontheimer, D., Fischer, C., and Buch, K. (2004) Kangaroo transport instead of incubator transport. Pediatrics 113(4),
920 – 923.
Ludington-Hoe, S.M. & Morgan, K. (2014). Infant assessment and reduction of sudden unexpected postnatal collapse risk
during skin-to-skin contact. Newborn & Infant Nursing Reviews 14, 28 - 33.
Ludington-Hoe, S.M. (2013). Kangaroo care as a neonatal therapy. Newborn & Infant Nursing Reviews 13, 73 – 75.
Ludington-Hoe, S.M., Morgan, K., Abouelfettoh, A. (2008). 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.
Ludington-Hoe, S., Anderson, G., Swinth, Thompson, C. and Hadeed, A. (2004). Randomized controlled trial of kangaroo
care: cardiorespiratory and thermal effects on healthy preterm infants. Neonatal Network 23(3), 39 – 48.
Ludington-Hoe, S., Ferreira, C., Swinth, J. and Ceccardi, J. (2003). Safe criteria and procedure for kangaroo care with
intubated preterm infants. JOGNN 32(5), 579 – 588.
Moore, E.R., Anderson, G.C., Bergman, N., & D owswell, T. (2012). Early skin-to-skin contact for mothers and their
healthy newborn infants. Cochrane Database Syst Rev 16:5, CD003519.
Morelius, E., Angelhoff, C., Eriksson, et al. (2012). Time of initiation of skin-to-skin contact in extremely preterm infants
in Sweden. Acta Paediatrica 101: 14 – 18.
Nagai, S., Yonemoto, N., Rabesandratana, N., et al. (2011). Long-term effects of earlier initiated continuous kangaroo
mother care for low-birth-weight infants in Madagascar. Acta Paediatrica 100, e241 – e247.
Nagai, S., Andrianarimanana, D., Rabesandratana, N.H., et al. (2010). Earlier versus later continuous kangaroo mother
care for stable low-birth-weight infants: a randomized controlled trial. Acta Paediatrica 99, 827 – 835.
Neu, M., Hazel, N.A., Robinson, J., et al. (2014). Effect of holding on co-regulation in preterm infants: a randomized
controlled trial. Early Human Development 90, 141 – 147.
Nimbalkar, S.M., Patel, V.K., Patel, D.V., et al. (2014). Effect of early skin-to-skin contact following normal delivery
on incidence of hypothermia in neonates more than 1800g: randomized control trial. Journal of Perinatolog 34,
364 – 368.
Nyqvist, K.H. (2010). State of the art and recommendations: kangaroo mother care; application in a high-tech
environment. Acta Paediatrica 99, 812 – 819.
Park, H., Choi, B.S., Lee, S.J. et al. (2014). Practical application of kangaroo mother care in preterm infants: clinical
characteristics and safety of kangaroo mother care. J Perinatal Medicine 42(2), 239 – 245.
Pejovic, N.J. & Herlneius, E. (2013). Unexpected collapse of healthy newborn infants: risk factors, supervision and
hypothermia treatment. Acta Paediatrica 102, 680 – 688.
Soukka, H., Gronroos, L., Leppasola, J. et al. (2014). The effects of skin-to-skin care on the diaphragmatic electrical
activity in preterm infants. Early Human Development 90, 531 – 534.
SBGH Neonatal Guideline Name: SKIN TO SKIN
(KANGAROO CARE)
Policy Number:
106
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Stevens, J., Schmied, V., Burns, E., & Dahlen, H. (2014). Immediate or early skin-to-skin contact after a Casesarean
section: a review of the literature. Maternal and Child Nutrition 10, 456 – 473.
Zhang, F. & Liu, S. (2012). Kangaroo mother care may help oral growth and development in premature infants. Fetal and
Pediatric Pathology 31: 191 – 194.
SBGH Neonatal Guideline Name: SKIN TO SKIN
(KANGAROO CARE)
Policy Number:
106
Page
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APPENDIX A:
Respiratory, Activity, Perfusion & Position (RAPP) Tool
To identify physiologic or positional conditions requiring nursing intervention to minimize risk.
See back of page for Guidelines for completion of RAPP tool.
Criteria
Birth time______
Into STS ______
RESPIRATIONS
Easy
Grunting/Flaring
Retractions
Tachypneic
Date______
Time______
Date_______
Time_______
Date______T
ime______
Date_______
Time_______
Date_______
Time_______
Date______
Time______
RN______
RN______
RN______
RN______
RN______
RN______
ACTIVITY
Asleep
Quiet Alert
Active Alert
Crying
Breastfeeding
Non-responsive
PERFUSION
Pink
Acrocyanosis
Pale
Dusky
POSITION/TONE
Head turned to one
side
Neck straight
Nares/mouth
visible
Well flexed
Some flexion
Limp/Flaccid
No recoil
RN Action*
Continue STS
Stop STS; to
radiant warmer/crib
Time STS ends
Duration of STS
**_____________
Any markings in the shaded areas require action by RN.
Actions could be: repositioned head/neck, uncovered mouth/nares, inclined parent, removed head covering, etc
** Calculate total minutes of time infant spent in STS and record here.
© KL Morgan, 2013
SBGH Neonatal Guideline Name: SKIN TO SKIN
(KANGAROO CARE)
Policy Number:
106
Page
6 of 7
Guidelines for completion of RAPP tool
Sudden unexpected postnatal collapse (SUPC) occurs when a previously vigorous, spontaneously breathing infant becomes
unexpectedly apneic. It may also present as acute cyanosis/pallor and unconsciousness, requiring respiratory support and
/or cardiac compressions. Incidence is 2.6 – 38/100,000 healthy infants.
Sequelae of SUPC ranges from no observable sequelae to severe adverse neurologic outcomes or death. Prevention of
SUPC involves identification of risk factors and vigilant postnatal monitoring.
Risk factors: Maternal: primiparity, fatigue, obesity, narcotics or magnesium sulfate, sedatives, side-lying position
Infant: head totally covered, occluded mouth or nose, bent neck, face up against breast
Complete RAPP assessment whenever you observe the infant.
RESPIRATIONS
Easy
Respiratory rate is 40 – 60/min, resps regular, no apnea, no increased work of breathing
i.e. no grunting, nasal flaring, retractions
Grunting/Flaring
RN Action required
Retractions
RN Action required
Tachypneic
RN Action required
ACTIVITY
Asleep
Quiet Alert
No gross body movements; eyes are open and appear attentive
Active Alert
Extremities, head or trunk are moving and eyes are attending to the environment. Movements
may be slow and dull or quick and sharp
Crying
May vary from a whimper to a lusty cry
Breastfeeding
Non-responsive
RN Action required
No response to tactile stimulation i.e. no movements, arousal, or change is physiology-If unresponsive, INITIATIVE RESUSCITATIVE MEASURES IMMEDIATELY
PERFUSION
Pink
Acrocyanosis
Pale
RN Action required
Dusky
RN Action required
POSITION/TONE
Head turned to one
side
Neck straight
Nares/mouth
visible
Well flexed
Some flexion
Limp/Flaccid
No recoil
RN Action*
Continue STS
Stop STS; to
radiant warmer/crib
Time STS ends
Duration of STS
Position parent upright i.e. sitting
Position infant prone on parent’s chest; ensure infant’s chest is in full contact with parent’s chest
Position Infant’s head upright and turned to one side
If an extremeity is not flexed, extend and release it quickly, watching for spontaneous recoil. If
spontaneous recoil is not seen, limb is limp or flaccid
RN Action required
RN Action required
RN Action required
SBGH Neonatal Guideline Name: SKIN TO SKIN
(KANGAROO CARE)
Policy Number:
106
Page
7 of 7
APPENDIX B
Safe Positioning Checklist
Safe Positioning for Skin-To-Skin Care
Checklist:
Face can be seen
Head is in “sniffing” position
Nose and mouth are not covered
Head is turned to one side
Neck is straight, not bent
Shoulders are flat against mom or dad
Chest – to - chest with mom or dad
Legs are flexed
Parent is a little upright, not flat, on
bed/chair
Baby’s back is covered with blankets
Both are watched when sleeping, or
baby is being monitored
If no one can watch you and your baby after feedings and when sleep is likely, put your
baby on his/her back in the baby’s own firm bed.