Click to edit Master title style Kangaroo Mother

Click to edit Master title style Kangaroo Mother care Method Science and Tenderness 2: The kangaroo Position • Module Click to edit Master text styles • Definition • – Modes of implementation Second level • Evidence based benefits • Third level • Implementation of the Kangaroo Position – Fourth level – Implementation of the initiation protocol – KP implementation in delivery room, » Fifth level – KP implementation After C-section – KP implementation when no care is available – KP implementation In NICU – KP implementation in intermediate and Minimal care unit • Annex 1: KP implementation in high technology units • Annex 2: Transfer to KP and back in NICU 11/27/2020 1

KMC Components Click to edit Master title style • 1 st Kangaroo position – The infant is placed almost naked in strict upright ventral position • Click to edit Master text styles between the mother´s breast, in direct contact with her skin, as long as possible – Second level • Third level • 2 nd Kangaroo Feeding and Nutrition strategy − Ideally exclusive breastfeeding to have a weight gain similar to the – Fourth level growth during the intra uterine life ( 15 g/Kg/day )until full term » Fifth level • 3 rd Early Discharge and strict ambulatory follow up − Discharge in kangaroo position regardless of weight and gestational age when the child is able to coordinate sucking, swallowing and breathing , gaining weight for 3 days and have parents informed , trained and ready to come to follow up visits 11/27/2020 2

Kangaroo Position : the Distinctive Click to edit Master title style Hallmark of KMC • Reference definition of the kangaroo position (KP) : • Click to edit Master text styles – The infant is placed almost naked (except hat, nappy and socks) in strict Second level upright ventral position between the mother´s breast, in direct contact with her skin, under her clothes, 24 hours a day • Third level • The cloth support helps to prevent the child’s airway from being – Fourth level obstructed and developing obstructive apneas » Fifth level • The baby may be fed at any time, while and still in KP • Any other person (e. g. the father), can share the mother role, carrying the baby in KP • The provider must sleep in a semi-sitting position (30°) • The KP is maintained until the baby no longer tolerates it 11/27/2020 3

Click to edit Master title style The Kangaroo Position • Click to edit Master text styles The kangaroo position is the distinctive hallmark of the Kangaroo – Second level • Third level Mother Care Method – Fourth level The kangaroo position has been the » basis Fifth level of parental involvement in the care of their preterm and/or low birth weight infant and is crucial for the humanization of care in neonatal units 11/27/2020 4

Conditions to use of the Kangaroo Position Click to edit Master title style Implementing KP in maternities and Neonatal Units requires preparation, motivation and training of health and • Click to edit Master text styles administrative staff : • – Need of a clear open door policy 24 h/24 h : Parents should: Second level – Have easy and rapid access to the hospitalized child • Third level – Be informed about hand washing and dressing policies – Fourth level – Have access to appropriate furniture, reclining chairs or » Fifth level equivalent to stay long periods of time with the child – Have access to food, restrooms, etc. • To reduce separation between mother and infant maternities and Neonatal Units staffs must be : – Flexible – Family friendly , inviting and supporting parents actively – Trained and have good communication skills 11/27/2020 5

Click to edit Master title style Initiation of the Kangaroo Position • Initiation as soon as it is possible and prudent to do so and if the • child is stable to tolerate it: Click to edit Master text styles • Having stable vital signs, – Second level • No bradycardia, • • No hypoxemia when manipulated, and Third level • Not presenting primary apnea or, if present, apnea is – Fourth level controlled » Fifth level • Initiation could be: • Immediately after birth (“healthy “preterm infants) and alert mother, or • Later when the child is able to tolerate it and the mother alert and willing 11/27/2020 6

Implementation of the Kangaroo Position Click to edit Master title style • Continuous kangaroo position • The child is placed in kangaroo position 24/24 hours, until he can regulate temperature and ‘asks to be removed’ from it • Click to edit Master text styles • Mother, father usually share the time and are the main providers of – Second level the kangaroo position ( grandparents , siblings can also participate, if trained) • Third level This mode of implementation is considered ideal, since it limits – Fourth level or avoids separating the child from his mother while in » Fifth level incubator • Intermittent kangaroo position • The child is placed in kangaroo position for short periods of time, one or several times a day for an uneven number of days It may be the only kangaroo position implementation mode or an adaptation process , leading to continuous kangaroo position according to the child’s status and the mother’s health and availability 11/27/2020 7

Click to edit Master title style Benefits of the Kangaroo Position • Click to edit Master text styles Since late 1980’, numerous studies in Neonatal Units – Second level and during follow up visits, preferably randomized • Third level controlled trials (RCT)conducted both in developed and – Fourth level developing countries documented the short and long » Fifth level term effects of the Kangaroo Position for the child, the mother, the family and the health facilities 11/27/2020 8

Global Benefits of the Kangaroo Position Click to edit Master title style § The kangaroo position fosters the progressive mother-infant inter • relation Click to edit Master text styles • Mother-Infant bond facilitates the main adaptations following birth: – Second level • Physiological stability of the infant Third level • • Immediate breast feeding Fourth level ––minimizes maternal stress and depression due to » Fifth level oxytocin release • Neurobehavioral organization § The mother becomes an active participant in the child stabilization process § The Kangaroo position increases the mother’s self-esteem and her confidence to care for her child 11/27/2020 9

Kangaroo Position and Thermo Regulation Click to edit Master title style Preterm / LBW infants can not regulate their temperature, they need to be in a neutral thermal environment to maintain • Click to edit Master text styles adequate body temperature without extra energy expenditure – Second level • Both kangaroo position and incubator can provide a neutral • Third level thermal environment safely and effectively – Fourth level • When healthy preterm infants are placed in Kangaroo position, » Fifth level the infant body temperature rises • At least 16 studies confirm temperature regulation during kangaroo position in a stable infant is as efficient as thermoregulation in an incubator Ludington-Hoe, Hashemi, Argote, Medellin, & Rey, 1992 11/27/2020 10

Kangaroo Position, Heart & Respiratory Rates Click to edit Master title style • In stable preterm infants in Kangaroo Position or in incubator the heart rate is similar and within the normal • Click to edit Master text styles Meta-analysis of 23 studies conducted with stable preterm infants, monitoring their heart rates in incubator, in kangaroo – Second level position and then back to the incubator, showed that variability of • Third level heart rates in those three moments was not significant and it remained within normal – Fourth level » Fifth level Acolet, Sleath, & Whitelaw, 1989 ; Wieland, Bauer, Bisson, Versmold, 1995 Clifford & Barnsteiner, 2001 • 2011, Cochrane Meta-analysis, confirmed that the respiratory rate of preterm infants in kangaroo position is lower, but normal, than in incubator Anderson, Moore, Hepworth, & Bergman 2003 11/27/2020 11

Kangaroo Position, Heart and Respiratory Rates Click to edit Master title style Regulation • Click to edit Master text styles • Heart and respiratory rates of preterm infants remain – Second level within normal limits during kangaroo position and are more • Third level stable than in incubator. – Fourth level » Fifth level Bergman, Linley, & Fawcus, 2004 11/27/2020 12

Kangaroo Position and Gastro esophageal Click to edit Master title style Reflux There are no studies that evaluate the relationship between kangaroo position and the incidence or severity of gastro • Click to edit Master text styles esophageal reflux – Second level But • Third level • Prevention and management of Gastro esophageal reflux – Fourth level recommends to maintain the child’s head above the level of » Fifth level the abdomen • The kangaroo position is similar to the generally recommended anti-reflux position • Kangaroo Position does not increase the risk of Gastro esophageal reflux 11/27/2020 13

Kangaroo Position and Oxygen saturation Click to edit Master title style • Oxygen saturation may increase between 2 - 3 % • Click to edit Master text styles during kangaroo position as compared with the incubator even during painful procedures – Second level • Third level Bier, Ferguson & al, 1996 • – Fourth level The evidence helps to confirm that oxygen » Fifth level saturation is variable, but remains within acceptable clinical standards. Ludington-Hoe, Morgan, & Abouelfettoh, 2008) 11/27/2020 14

Kangaroo Position and Apneas Click to edit Master title style Controlling the position of the child’s head and neck as in Kangaroo position is essential in order to guarantee the • Click to edit Master text styles stability of breathing and avoid apneas due to obstruction of – Second level the air way • Third level • There is no direct evidence that the kangaroo position prevents the incidence or severity of episodes of apnea of the prematurity – Fourth level • In short periods and in stable patients, the frequency of apnea » Fifth level and periodical breathing are similar to those observed in the same children while in incubators • Evidence has demonstrated that newborns in the kangaroo position doesn’t have an increased risk for apnea 11/27/2020 15

Kangaroo Position and Stress and Pain Click to edit Master title style • Premature infants placed on the mother’s chest in kangaroo • position are observed to be more relaxed, calmer, and able to Click to edit Master text styles sleep more easy – Second level Ludington-Hoe, Johnson, Morgan, & al. , 2006 • Maintaining the child in kangaroo position during painful • Third level procedures, has demonstrated to reduce the intensity and – Fourth level duration of subsequent crying » Fifth level Kostandy, Ludington-Hoe, Cong, Abouelfettoh, Bronson, & al, 2008 The American Academy of Pediatrics recommends using the kangaroo position in order to reduce the intensity and duration of the reaction triggered by mildly to moderately painful procedures Anderson, Moore, Hepworth, & Bergman, 2003 11/27/2020 16

Kangaroo Position and Breastfeeding Click to edit Master title style • Researches demonstrated that mothers who are in skin-to-skin contact with their children have more milk than those in the control group Bier A. , Ferguson, Liebling, & al. , 1995; • Click to edit Master text styles Conde-Aqudela, Diaz-Rossello, &Belizan, 2003 – Second level • 98 % of preterm infants placed in kangaroo position 13, 5 hours a day received exclusive breast milk at 40 weeks gestational age, as • Third level compared with 76 % of those who were not in kangaroo position – Fourth level Suman, Udani, & Nanavati, 2008 » Fifth level • 55% of infants weighing less than 1500 g, was breastfed at six weeks in skin-to-skin contact groups compared with 28% of those not in skin to skin contact Whitelaw, Heisterkamp, Sleath, Acolet, & Richards, 1998 • Breastfeeding up to 5, 08 months in skin to skin group compared with 2, 05 months in non skin to skin group 11/27/2020 Hake-Brooks & Anderson, 2008; Moore & Anderson, 2007 Moore, Anderson, & Bergman, 2007 17

Kangaroo Position and Neurologic Click to edit Master title style Development and Sleep • The Kangaroo Position fosters early neurologic development in the • preterm infant, improving behavioral organization: Click to edit Master text styles – Better organization in the sleep-wake cycles ++ – – Better quality of sleep ++ Second level – Maturation of neurologic and psycho-motor functions as measured by • Third level standardized tests – Fourth level • A greater complexity in brain has been observed in 32 to 40 weeks of » Fifth level gestational age placed in kangaroo position, as opposed to those who were not • 5 regions of the right hemisphere show greater maturation in children placed in kangaroo position Ludington-Hoe, Morgan, Abouelfettoh, 2008 11/27/2020 18

Kangaroo Position and State of Alertness Click to edit Master title style Hospital stress impairs the preterm infant's neurobehavioral outcome • It has been demonstrated , that the Kangaroo Position minimizes the • Click to edit Master text styles negative impact of hospital stay on development Collados-Gómez, Aragonés-Corral, Contreras -Olivares, García-Faced, & al, 2011 – Second level • Kangaroo position improve the quality and duration of the periods of deep • Third level sleep++ – Fourth level • Children in kangaroo position cry less than in the incubator. » Fifth level Lehtonen & Martin, 2004; Messmer, Rodriguez, Adams, & al. , 1997 Mc. Cain, Ludington-Hoe, Swinth, & Hadeed, 2005 • The kangaroo position used 5 times a week, for more than 30 minutes increases the states of alertness and attention of children evaluated at 37 weeks of gestational age, 6 and 12 months Chiu & Anderson, 2009 11/27/2020 19

Implementation of Kangaroo Position (1) Click to edit Master title style Use of a standardized protocol based on scientific evidences for adaptation and implementation of the kangaroo position to maximize the benefits for children and parents and to limit the risks 1. Information of mothers/parents : It is fundamental to preparents, – Second level especially mothers before implementing the KP – If risk of preterm delivery the benefits of the position must be repeated to • Third level motivate the mother to be with her child as much possible – Fourth level – All practical aspects of visits or prolonged/permanent stay during the » Fifth level child’s hospitalization should be explain to parents 2. Identification of beneficiary dyads mother-infant to KP: A member of the team usually a nurse, identify, at an early time, the infants who could benefit from the kangaroo position − In delivery room , in immediate post partum (mother and infant rooming in together), or in neonatal unit or nursery The mother is the ideal and main provider of the KP but if she is unavailable, the father or any family member can immediately begin the kangaroo position • Click to edit Master text styles 11/27/2020 20

Implementation of Kangaroo Position (2) Click to edit Master title style 3. Assessment of clinical status of infant and mother : the situation of infant and • Click to edit Master text styles mother must be evaluated to decide to begin the KP − The ideal is to begin as soon as possible, if the baby is close to term and the –mother is alert, KP starts in the delivery room Second level 4. Adequate clothes for mother and infant • Third level − Mother/kangaroo provider must wear clothes with frontal access – Fourth level − A support system must be provided in order to hold the baby(Lycra™ girdle or band) » Fifth level − The infant should be naked except a cap ( wool or cotton) , a sleeveless cotton shirt open in the front, socks and a diaper 5. Placing the infant in Kangaroo position requires trained staff − The mother must hold him by placing one hand on the neck and back, with her fingers under his chin, the other hand is placed under the baby’s buttocks − The kangaroo baby is in upright position and ventral decubitus, with his body and head against the mother’s chest, in a” frog-like position” 11/27/2020 21

Implementation of Kangaroo position (3) Click to edit Master title style 6. Maintaining Kangaroo position and feeding The kangaroo baby must always be kept in kangaroo position, safe for diaper • −Click to edit Master text styles change and breast feeding Second level − – During breastfeeding, the lateral position is recommended allowing skin-toskin contact • Third level − The child should be in skin-to-skin contact, ideally 24 /24 hours – Fourth level − The kangaroo provider must sleep in a reclined position, of at least 30º 7. Monitoring the » adaptation Fifth levelto the kangaroo position for infant and mother to maintain or to interrupt it − Assess the baby for the regularity of breathing, state of alertness, color, general aspect, posture, apparent comfort or discomfort, sleep and alert periods in kangaroo position − Assess the mother’s attitudes, tolerance and emotional state − Monitoring of adaptation of the kangaroo provider-child dyad must be done by a trained staff under the supervision of the pediatrician 11/27/2020 22

Eligibility criteria for Kangaroo Position at Birth Click to edit Master title style (In delivery room or after caesarian section) • The child is stable: • Click to edit Master text styles • All vital signs and other physiological parameters (except temperature) are – within normal ranges, during manipulation to place and keep him in kangaroo Second level position • A kangaroo Provider, ideally the mother is identified • Third level • Free from fever, contagious , neurological or mental diseases – Fourth level • Alert, recovering from general anesthesia » Fifth level • Informed about kangaroo position • Willing to implement Kangaroo position • In case of mother after C-section, surgery or illness : If the mother cannot provide kangaroo care: • The father or a substitute can a kangaroo provider from birth • A picture of the child may be taken and given to the mother • The mother will come to the NICU as soon as possible and if she is transferred the infant will be brought to her 11/27/2020 23

Kangaroo Position when no Resources are Click to edit Master title style Available Refers to a premature delivery or the birth of a LBW infant, in a rural community or hospital, without special equipment and without specialists to care for the infant – Second level 1. If possible transfer preterm or LBW infants in kangaroo position to a health institution with the adequate equipment and staffing • Third level 2. If transfer is not possible: – Fourth level - Dry thoroughly the infant » Fifth level - Place the infant in kangaroo position , protected by mother clothes and blanket - Give colostrum then breast milk with a dropper, a spoon or a catheter to avoid hypoglycemia The kangaroo position offers good temporary protection against hypothermia, primary apneas of prematurity and hypoglycemia but will not treat pathologies • Click to edit Master text styles 11/27/2020 24

The Kangaroo Position in the Neonatal Click to edit Master title style Intensive Care Unit • • The advantages offered by the kangaroo position Click to edit Master text styles (increasing physiological stability, increasing milk production, reducing risk of nosocomial infection, decreasing pain and stress, improving brain maturation and neurobehavioral – Second level development ) as well as the possibility of avoiding separating the infant • Third level and parents ( decreasing maternal anxiety , improving bonding with the – Fourth level parents making them primary and active part of their child’s recovery) are good reasons to implement it in NICU in stable infants » Fifth level • If the infant is in a critical state, the kangaroo position may be inappropriate The decision to adopt the position must be made based on local experience, local protocol and always with authorization and close supervision of the neonatologist/pediatrician 11/27/2020 25

Parent preparation in case of NICU Click to edit Master title style hospitalization • All parents must be informed : • Of any risk during the pregnancy creating a risk of premature delivery • Click to edit Master text styles • Of the possibility for the infant to be admitted to the NICU and the benefit of it Second level • – About therapeutic value of the kangaroo position when it will be possible • Third level • Parents should be familiarized with medical equipment and staff – Fourth level » Fifth level • It is crucial to explain to parents the reasons and aims of procedures implemented on their infant • As much as possible, activities, such as tube feeding, diaper change, blood samplings, intravenous injections and thoracic auscultation must be performed on the child in kangaroo position 11/27/2020 26

Preparation of Parents to Kangaroo Click to edit Master title style Position in NICU Click to edit Master text styles • • Offer appropriate information on how the kangaroo position is initiated to preparents to make of this contact a pleasant, positive and – Second level unforgettable situation • Third level – Fourth level • Determine whether the parents are eligible to begin the kangaroo » Fifth level position based on the assessment of the following aspects • • • Parent health including emotional state & anxiety management Expressed will to begin kangaroo position Knowledge about KMC Decision to breast feed Available time 11/27/2020 27

Preparation of Health teams to implement Click to edit Master title style Kangaroo Position in NICU • The health team must be sensitive not only to the newborn • but also to his family Click to edit Master text styles – Having families involved in their baby’s care improves the quality of –care, making care more humane raising feelings of satisfaction and Second level competence in the medical team • Third level • The NICU health team must work according to their own – Fourth level protocols , requirements and skills » Fifth level – Defines eligibility criteria and contraindications • The team must: – Acquire the ability to implement the kangaroo position, – Be prepared and able to teach the parents to detect alarm signs – Receive permanent update on the development of the KMC Method 11/27/2020 28

Eligibility criteria for Kangaroo Position in NICU Click to edit Master title style Eligibility criteria for kangaroo position in NICU result of I mplementing the KMC in Neonatal Units in Bogota (Colombia) Click to edit Master text styles • • Preterm infants ≥ 30 weeks are eligible for KP if they have s table vital signs within normal range at rest – Second level Some anomalies in vital signs may be present not preventing KP : • Third level – Tachycardia resulting from agitation – Fourth level – Bradycardia between 85 -100 beats/min with spontaneous recovery and » Fifth level not more often more than 1 to 3 times in an hour. – Respiratory pause lasting less than 10 seconds less than 3 times per hour without desaturation – Desaturations, up to 85 %, with spontaneous oxygen recovery • Tolerance to manipulation quick recovery when manipulation is over • Oxygen (hood or nasal cannula) • Blood gases: within normal parameters 11/27/2020 29

Contraindications for Kangaroo Position Click to edit Master title style in NICU (1) Kangaroo position must not be started in preterm infants • Click to edit Master text styles • • • presenting physiological instability or a deterioration of – Second level the clinical condition and vital signs in the last 24 hours: Moderate hypothermia while in incubator • Third level Anomalies in the blood pressure ( hypotension or hypertension) – Fourth level Bradycardia < 85 beats/min of any duration or heart rate 85» Fifth level 100 beats/ min more than 4 times per hour Apneas with a desaturation < 85 % or any respiratory pause > 10 seconds or that requires stimulation Any desaturation < 85 % Physiological instability when manipulated 11/27/2020 30

Contraindications for Kangaroo Click to edit Master title style Position in NICU (2) • Difficult position of venous or arterial access which makes them unstable • (central catheters, arterial lines, umbilical arterial catheters, thoracic Click to edit Master text styles tubes) – Second level • Use of vasopressor drug • Mechanical ventilation with increasing parameters in the last 24 hours, • Third level fluctuation of the ventilation parameters – Fourth level • Life-threatening medical conditions in the last 24 hours » Fifth level • Intracranial hemorrhage grade III-IV • Cardiorespiratory arrest • Clinical signs or laboratory parameters of sepsis • Immediate post-operatory period • Abnormal blood gases • Compromised neurological state due to lethargy and severe hypotonia 11/27/2020 31

Transfer from Incubator to Kangaroo Click to edit Master title style Position of Infant with Assisted Ventilation • The easiest way to do this transfer is by standing and picking the child up Click to edit Master text styles • The other parent or the nurse disconnects the ventilator from the – Second level tracheal tube before the transfer and reconnects it as soon as kangaroo • Third level provider sits down with the infant – Fourth level • During the transfer, 1 or 2 persons (depending on the number of tubes » Fifth level and lines connecting the infant to the monitor, ventilator or infusion pumps) holds and secures the ventilation tube and lines to the baby’s clothes with adhesive tape • The mother must have mirror to observe the baby without moving him • A nurse should support and monitor the transfer until the parents are able to do it on their own 11/27/2020 32

The Kangaroo Position in Intermediate Click to edit Master title style and Minimal Care Units In the Intermediate or Minimal Care Units the KP can be up to 24 • Click to edit Master text styles hours or the discharge in KP can be proposed if possible – Second level • Eligibility criteria : Infants physiologically stable for at least the last 24 hours , even if: • Third level – Oxygen ( chamber or nasal cannula) with a normal saturation while in – Fourth level the position » Fifth level – Parenteral fluids adequately held in place – Partial or total oral feedings, even with gavage • Not eligible infants – Infants with open wounds or important skin lesions – Infants under continuous phototherapy with no biliblanket – Infant with unstable metabolic situation 11/27/2020 33

Transfer from incubator to Kangaroo Click to edit Master title style Position Parents prepare the infant for transfer by holding him, in the incubator, softly with their hands for a while, before picking him up • Click to edit Master text styles – Second level • Transfer while standing: The position provider leans slightly forward, picks • Third level up the infant in a flexed position, places the child in kangaroo position on – Fourth level his chest and returns to the chair/bed, sitting or reclining in a comfortable » Fifth level position • Transfer while sitting: A nurse or the other parent picks the baby up, maintaining support in a flexed position for arms and legs and places him in kangaroo position on the other parent’s chest, once he or she is seated 11/27/2020 34

Transfer in Kangaroo Position Click to edit Master title style • Transportation of newborn, rapidly and under optimal • conditions, protect and often to safe the infant’s life Click to edit Master text styles – Second level • To transport “stable “ infant in kangaroo Position is • Third level – Fourth level an effective alternative in case of scarce or non» Fifth level existent specialized transportation • It is inappropriate to transport in Kangaroo position critically ill children 11/27/2020 35

Click to edit Master title style Conclusion • Click to edit Master text styles – Second level • The kangaroo position has been the basis of • Third level – Fourth level parental involvement in the care of their preterm » Fifth level and/or low birth weight infant and is crucial for the humanization of care in neonatal units 11/27/2020 36