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Kangaroo Mother care Method
Science and Tenderness
2: The kangaroo Position
•Module
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• Definition
• –
Modes
of implementation
Second
level
• Evidence based benefits
• Third levelof the Kangaroo Position
• Implementation
– Fourth levelof the initiation protocol
– Implementation
– KP implementation
» Fifth level in delivery room,
– 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
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1
KMC
Components
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• 1st Kangaroo position
– The infant is placed almost naked in strict upright ventral position
between the mother´s breast, in direct contact with her skin, as long
as possible
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– Second level
• Third Feeding
level and Nutrition strategy
• 2nd Kangaroo
− Ideally
breastfeeding to have a weight gain similar to the
– exclusive
Fourth level
growth during
the
intra uterine life ( 15 g/Kg/day )until full term
» Fifth
level
•
3rd 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
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2
Kangaroo Position : the Distinctive
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Hallmark of KMC
• Reference
definition
of thestyles
kangaroo position (KP) :
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text
–
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
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3
Click to editThe
Master
titlePosition
style
Kangaroo
• Click to edit Master
textposition
stylesis the
The kangaroo
distinctive hallmark of the Kangaroo
– Second level
• Third level
Mother Care Method
– Fourth
Thelevel
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
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4
Conditions
to use
of the Kangaroo
Position
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Implementing KP in maternities and Neonatal Units requires
preparation, motivation and training of health and
• Clickadministrative
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staff : text styles
• –
Need
of a clear
open door policy 24h/24h : Parents should:
Second
level
– Have easy and rapid access to the hospitalized child
• Third
levelabout hand washing and dressing policies
– Be
informed
Fourth to
level
– Have– access
appropriate furniture, reclining chairs or
» Fifth
levellong periods of time with the child
equivalent
to stay
– 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
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5
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Initiation
of the
Kangaroo
Position
• Initiation as soon as it is possible and prudent to do so and if the
is stable able to tolerate it:
• child
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to
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• Having stable vital signs,
– Second
level
• No bradycardia,
•• No
hypoxemia
when manipulated, and
Third
level
• Not
– presenting
Fourth level primary apnea or, if present, apnea is
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
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Implementation
of the Kangaroo
Position
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• Continuous kangaroo position
• The child is placed in kangaroo position 24/24 hours, until he can
regulate
temperature
and ‘asks
be removed’ from it
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to edit
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texttostyles
• 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
oflevel
implementation is considered ideal, since it limits
Fourth
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
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7
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Benefits
of theMaster
Kangaroo
Position
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Since late 1980’, numerous studies in Neonatal Units
– Second
and
duringlevel
follow up visits, preferably randomized
• Third
level(RCT)conducted both in developed and
controlled
trials
– 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
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8
Globalto
Benefits
of the Kangaroo
Position
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 The kangaroo position fosters the progressive mother-infant inter• relation
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• Mother-Infant bond facilitates the main adaptations following birth:
– Second
level stability of the infant
• Physiological
Third levelbreast feeding
•• Immediate
Fourth levelmaternal stress and depression due to
–– minimizes
» Fifth release
level
oxytocin
• 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
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9
Kangaroo
Position
and Thermo
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to edit
Master
titleRegulation
style
•
Preterm / LBW infants can not regulate their temperature, they
to be in a neutral thermal environment to maintain
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to
edit
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text
styles
adequate body temperature without extra energy expenditure
– Second level
• Both •kangaroo
position and incubator can provide a neutral thermal
Third level
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
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Kangaroo
Heart & Respiratory
Click toPosition,
edit Master
title styleRates
• In stable preterm infants in Kangaroo Position or in incubator the
heart rate is similar and within the normal
• ClickMeta-analysis
to edit Master
text
styles
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
•heart
Third
level
rates
in those three moments was not significant and it
remained
within
– Fourth
levelnormal
» 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
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Kangaroo Position, Heart and Respiratory Rates
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Regulationtitle style
• Click to edit Master text styles
• Heart and respiratory rates of preterm infants remain within
– Second level
normal limits during kangaroo position and are more stable
level
than•inThird
incubator.
– Fourth level
» Fifth level
Bergman, Linley, & Fawcus, 2004
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Kangaroo Position and Gastro esophageal
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There are no studies that evaluate the relationship between
position
the incidence
or severity of gastro
•kangaroo
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edit and
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
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13
Kangaroo
and Oxygen
saturation
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title style
• Oxygen saturation may increase between 2 - 3 %
• Click
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textasstyles
duringtokangaroo
position
compared with the
incubator
even during painful procedures
– Second level
• Third level
– Fourth level
evidence
helps
» Fifth
level
Bier, Ferguson & al, 1996
• The
to confirm that oxygen
saturation is variable, but remains within
acceptable clinical standards.
Ludington-Hoe, Morgan, & Abouelfettoh, 2008)
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Kangaroo
Position
and
Apneas
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Controlling the position of the child’s head and neck as in
position istext
essential
in order to guarantee the
• Click toKangaroo
edit Master
styles
stability of breathing and avoid apneas due to obstruction of
– Second level
the air way
levelevidence that the kangaroo position prevents
• There• isThird
no direct
the incidence
or severity
of episodes of apnea of the prematurity
– Fourth
level
• In short periods
» Fifth
andlevel
in stable patients, the frequency of apnea
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
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Kangaroo Position and Stress and Pain
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• Premature infants placed on the mother’s chest in kangaroo
observed
to be more
• position
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Master
textrelaxed,
stylescalmer, and able to
sleep more easy
– Second level
Ludington-Hoe, Johnson, Morgan, & al., 2006
• Maintaining
child in kangaroo position during painful
• Third the
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
4/7/2015
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Kangaroo
Position
and Breastfeeding
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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 to edit Master text styles
Bier A. , Ferguson, Liebling, & al., 1995;
• Click
Conde-Aqudela,Diaz-Rossello,&Belizan, 2003
– Second
level
• 98
% of preterm
infants placed in kangaroo position 13,5 hours a day
received
exclusive
• Third
levelbreast milk at 40 weeks gestational age, as
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
Hake-Brooks & Anderson, 2008;Moore & Anderson, 2007
Moore, Anderson, & Bergman, 2007
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Kangaroo Position and Neurologic
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Development and Sleep
• The Kangaroo Position fosters early neurologic development in the
preterm infant, improving behavioral organization:
– Better organization in the sleep-wake cycles ++
–
quality
of sleep ++
– Better
Second
level
– Maturation of neurologic and psycho-motor functions as measured by
• Third level
standardized
tests
– Fourth level
• A greater complexity
brain has been observed in 32 to 40 weeks of
» Fifth in
level
gestational age placed in kangaroo position, as opposed to those who
were not
• Click to edit Master text styles
• 5 regions of the right hemisphere show greater maturation in children
placed in kangaroo position
Ludington-Hoe, Morgan,Abouelfettoh, 2008
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Kangaroo
and State
Alertness
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titleofstyle
Hospital stress impairs the preterm infant's neurobehavioral outcome
• It has been demonstrated , that the Kangaroo Position minimizes the
negative impact of hospital stay on development
• Click to edit Master text styles
Collados-Gómez,
– Second
levelAragonés-Corral, Contreras -Olivares, García-Faced, & al, 2011
• 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.
» Lehtonen
Fifth level
& Martin, 2004; Messmer, Rodriguez, Adams, & al., 1997
McCain, 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
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Implementation of Kangaroo Position (1)
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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 prepare parents,
– Second
level
especially
mothers
before implementing the KP
– If risk of preterm delivery the benefits of the position must be repeated
• Third level
to 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
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Implementation
of
Kangaroo
Position
(2)
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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
is alert,
KP starts in the delivery room
– mother
Second
level
4.Adequate clothes for mother and infant
−
−
−
• Third level
Mother/kangaroo provider must wear clothes with frontal access
– Fourth
level be provided in order to hold the baby(Lycra™ girdle or
A support
system must
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”
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Implementation
Kangaroo
position
Click to editofMaster
title
style (3)
6. Maintaining Kangaroo position and feeding
The kangaroo
babyMaster
must alwaystext
be keptstyles
in kangaroo position, safe for diaper
• −Click
to edit
change and breast feeding
Second
level the lateral position is recommended allowing skin-to− – During
breastfeeding,
skin contact
• Third level
− The child should be in skin-to-skin contact, ideally 24 /24 hours
– Fourth
levelmust sleep in a reclined position, of at least 30º
− The kangaroo
provider
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
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Eligibility criteria for Kangaroo Position at Birth
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to edit
Master
title style
(In delivery
room
or after caesarian
section)
• The child is stable:
• Click
tosigns
edit
textparameters
styles(except temperature) are
• All vital
and Master
other physiological
–
within normal ranges, during manipulation to place and keep him in kangaroo
Second
level
position
• A kangaroo
Provider,
• Third
level ideally the mother is identified
•
•
•
•
•
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
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Kangaroo Position when no Resources are
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Availabletitle style
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
levelpreterm or LBW infants in kangaroo position to a
1. –
If possible
transfer
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
4/7/2015
24
The Kangaroo Position in the Neonatal
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Master
title
style
Intensive Care Unit
• Click to edit Master text styles
• The advantages offered by the kangaroo position (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
parents making
themlevel
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
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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
• Of the possibility for the infant to be admitted to the NICU and the
benefit of it
Second
level value of the kangaroo position when it will be
•– About
the therapeutic
possible
• Third level
• Parents should be familiarized with medical equipment and staff
– Fourth level
» Fifthtolevel
• It is crucial to explain
parents the reasons and aims of procedures
• Click to edit Master text styles
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
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Preparation of Parents to Kangaroo
Click to Position
edit Master
title style
in NICU
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to editinformation
Masterontext
• •Offer
appropriate
how styles
the kangaroo position is initiated
to prepare parents to make of this contact a pleasant, positive and
– Second level
unforgettable situation
• Third level
– Fourth the
levelparents are eligible to begin the kangaroo
• Determine whether
» 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
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Preparation of Health teams to implement
Click toKangaroo
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title
style
Position in NICU
• The health team must be sensitive not only to the newborn
also to
to his
family
• but
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edit
Master text styles
– Having families involved in their baby’s care improves the quality of
–care,
Second
makinglevel
care more humane raising feelings of satisfaction and
competence
in the medical team
• Third level
• The NICU –health
Fourthteam
level must work according to their own
protocols , requirements
» Fifth level and skills
– 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
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Eligibility criteria for Kangaroo Position in NICU
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Eligibility criteria for kangaroo position in NICU result of I
mplementing the KMC in Neonatal Units in Bogota (Colombia)
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edit
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styles
• • Preterm
infants
≥ 30
weeks aretext
eligible
for KP if they have stable
vital
signs within
normal range at rest
– Second
level
Some •anomalies
Third levelin vital signs may be present not preventing KP :
– Tachycardia
resulting
– Fourth
levelfrom agitation
– 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
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Contraindications for Kangaroo Position
Click to editinMaster
title
style
NICU (1)
must
not be
started in preterm infants
• ClickKangaroo
to editposition
Master
text
styles
•
•
•
•
•
•
presenting physiological instability or a deterioration of
– Second
level
the clinical
condition and vital signs in the last 24 hours:
Moderate
while in incubator
• Thirdhypothermia
level
Anomalies
in thelevel
blood pressure ( hypotension or hypertension)
– Fourth
Bradycardia <» Fifth
85 beats/min
of any duration or heart rate 85level
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
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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
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
• Click to edit Master text styles
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Transfer
fromMaster
Incubatortitle
to Kangaroo
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to edit
style
Position of Infant with Assisted Ventilation
• Click
to edit
textis by
styles
The easiest
way to Master
do this transfer
standing and picking the child up
• 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
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The Kangaroo Position in Intermediate
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Master
style
andedit
Minimal
Caretitle
Units
or Minimal
Units the KP can be up to 24
• ClickIn the
to Intermediate
edit Master
textCare
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
Thirdif:level
– Oxygen
( chamber
– Fourth
levelor nasal cannula) with a normal saturation while in
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
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Transfer from incubator to Kangaroo
Click to editPosition
Master title style
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
• infant
Thirdinlevel
up the
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
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Transfer
in Kangaroo
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to edit
Master Position
title style
• Transportation of newborn, rapidly and under optimal
• conditions,
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Master
text
styles
protect and often to safe the infant’s life
– Second level
• To transport
“stable “ infant in kangaroo Position is an
• Third level
Fourth level in case of scarce or non-existent
effective– alternative
Fifth level
specialized »transportation
• It is inappropriate to transport in Kangaroo position
critically ill children
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Master title style
Conclusion
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– Second level
• The• kangaroo
Third level position has been the basis of
– Fourth
level
parental
involvement
in the care of their preterm
» Fifth
levelweight infant and is crucial for the
and/or low
birth
humanization of care in neonatal units
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