Nursing Research: Kangaroo Care

Most nurses working in an intensive care nursery have witnessed parents expressing in-tense need to hold their ill preterm infants. A new method of care addressing this need is “kangaroo care,” a term derived from its similarity to the way marsupials mother their immature young. During kangaroo care (KC), mothers simply hold their diaper-clad infant underneath their clothing, skin-to-skin, and upright between their breasts; if
needed for warmth, a cap and a blanket across the infant’s back may be added. Incomplete kangaroo care mothers allow self regulatory breast-feeding. In developing countries the method is called kangaroo mother care (KMC), because mothers are usually the central figure responsible for care and they breast-feed exclusively. Kangaroo care, also known as skin-to-skin contact (SSC), is widespread in Scandinavia and Africa and is proliferating elsewhere. The method, which originated in Bogota´ , Colombia, represents a blend of technology and natural care. Full-term infants also are vulnerable during the physiologically demanding intrauterine-extrauterine transition following birth and therefore benefit from kangaroo care (Anderson, G. C., Moore, Hepworth, &Bergman, 2003).

new born

Relevant theoretical paradigms include stress, mutual caregiving, and self-regulation (Anderson, G. C., 1977, 1989, 1999), programming, inappropriate stress responsivity, and allostatic load, all of which are physio-logical/developmental and life span in nature; and Fitzpatrick’s Rhythm Model, Levine’s Energy Principles, Nightingale’s Model, Orem’s Self-Care Model, Rogers’ Energy Fields, and Roy’s Adaptation Model (Fitzpatrick, J. J., & Whall, 1989). There are five categories of kangaroo care, based primarily on how soon kangaroo care begins (Anderson, G. C., 1995). Late Kangaroo Care, still the most common category in the U.S., begins when infants are stable in room air and approaching discharge. Infants given Intermediate Kangaroo Care have completed the early intensive care phase, but usually still need oxygen and probably have some apnea and bradycardia. Also included in this category are infants who are stabilized with mechanical ventilation and infants who, al-though too weak to nurse, are placed at the breast during gavage feedings, a method that facilitates lactation. Early Kangaroo Care is used for infants who are easily stabilized and begins as soon as infants become stable, usually during the 1st week and perhaps even the 1st day post birth. The idea is that mothers can help maintain stability by giving kangaroo care. Very Early Kangaroo Care begins in the delivery or recovery room between 15and 60 minutes post birth. With Birth Kangaroo Care the infant is returned to the mother immediately following birth. The rationale in these last two categories is that the mother can help to stabilize her infant.
Numerous important extensions of kangaroo care have been reported as separate case studies, mostly in MCN, The American Journal of Maternal-Child Nursing; examples are with twins, triplets, an intubated preterm infant, full-term infants having breast-feeding difficulties, a near-term infant with gastric reflux, adoptive parents, and a mother who felt depressed during early postpartum (Anderson, G. C., Dombrowski, & Swinth,2001). Other journals that frequently carry kangaroo care articles include Acta Paediatrica (formerly Acta Paediatrica Scandinavica); Journal of Obstetric, Gynecologic, and Neonatal Nursing (JOGNN); and Neonatal Network, the Journal of Neonatal Nursing. Kangaroo care is safe and has health benefits based on evidence (Anderson, G. C.,1991, 1995, 1999). In the United States nurses have done most of this research. Findings included adequate warmth, energy conservation, regular heart rate and respirations, four fold decrease in apnea, adequate oxygenation, more deep sleep and alert inactivity, less crying, less cranial deformity, no increase in infections, fewer days in incubators, greater weight gain, and earlier discharge; lactation and breast-feeding increase and last longer. Kangaroo care, especially during breast-feeding, was analgesic for infants, pro-vided mothers feel relaxed. Fathers also gave kangaroo care effectively, as do grandparents, young siblings, and selected important others. Parents feel more fulfilled, become deeply attached to their infants, and feel confident about caring for them even at home. Cost-effectiveness and improved long-term outcomes exist but are not yet evidence-based.
The National Institute of Nursing Re-search has funded nurses to conduct six randomized trials with preterm infants in which kangaroo care was the intervention. Five trials have been conducted by Ludington; three completed trials were with infants in open air cribs, in incubators, and on mechanical ventilation (e.g., Ludington et al., 2003). Two trials are in progress: one on sleep and brain development measured by electroencephalogram and the other on blunting of pain measured by heart rate variability. The sixth trial was with 32–36 week healthy infants beginning kangaroo care on average 4.5 hours post birth (e.g., Anderson, G. C., Chiu, et al.,2003). In a pilot trial for the funded trial, 34–36 week infants began almost continuous kangaroo care by 30 minutes post birth, had remarkable behavioral organization, began breast-feeding exclusively by 2 hours, and were breast-feeding competently within 24 hours. Importantly, two infants had developed respiratory distress (grunting) by the time kangaroo care began, but this disappeared quickly while the infants stayed in kangaroo care and received warmed humidified oxygen via oxyhood; the warmth and humidity are essential (Anderson, G. C., 1999). Seven randomized trials done in developing countries, numerous others in Europe, and two in Taiwan have led to additional publications.

Although fully implemented in some hospitals, use of the kangaroo care method generally remains scattered. The method is not allowed in some hospitals and may not last in others due to resistance from some hospital staff with resultant variable support for parents. An elegant model for introducing the method and effecting desired change and implementation is described by Bell and McGrath (1996). Because kangaroo care benefits are dose-related, parental burdens such as time required, fatigue, discomfort, home related responsibilities, stress, and anxiety warrant creative initiatives including broad social services to facilitate relaxation and extend caregiving (Anderson, G. C., Chiu, et al., 2003). Other trends in kangaroo care include increasingly rigorous research, federal funding, publication of detailed guidelines (e.g., by WHO[2003a], available online), conferences devoted to kangaroo care, kangaroo care for sicker infants and for full-term infants, kangaroo care provided by selected family members or friends, consumer awareness of and desire for kangaroo care, and increased use of kangaroo care to facilitate lactation and breast-feeding especially for dyads having breast-feeding difficulties. The new realization that very early kangaroo care can help stabilize some preterm infants and prevent NICU admission has increased interest in giving kangaroo care as soon as possible post birth, as often as possible thereafter, and for as long as possible each time. Nursing research is needed to document the great potential that kangaroo care in its various forms has for quality care, mutual relaxation and stress reduction, improved outcomes, parental satisfaction, and cost reduction.