Susan M. Ludington CNM, CKC, PhD, FAANKathy Morgan RN, NNP-BC CKC

Pre-conference Power point # 2

National Recommendations and Guidelines for the use of

Kangaroo Care

Objectives1. To identify national organizations that recommend the use of Kangaroo Care (KC)2. To review the process of how the evidence behind KC becomes national guidelines for practice3. To review some of the most recent recommendations for KC4. To discuss how Kangaroo Care can help your institution to achieve Baby Friendly Status5. To identify recommendations of the Center for Disease

Control and Prevention for KC to increase exclusive breast milk feedings

6. To identify your institution’s readiness to implement KC

Since the initial use of Skin-to-Skin contact by Klaus and Kennell (1970) with preterm infants in Cleveland, OH there has been a multitude of research on the benefits of KC Professional organizations have recognized its’ value and have made recommendations for the use of KC with both full term and preterm infants

Introduction

Kennell JH. Klaus MH. 1970.Care of the mother of the high risk infant. Clin Obstet Gynecol.14(3):926-954

Obj 1: Which organizations recommend Kangaroo Care?• World Health Organization • Centers for Disease Control and Prevention USA• American Academy of Pediatrics• American Academy of Family Physicians• Academy of Breastfeeding Medicine• American College of Obstetricians and Gynecologists (ACOG)• American Heart Association (NRP)• Association of Women’s Health, Obstetric and Neonatal Nurses

(AWHONN)• American College of Nurse Midwives • National Association of Neonatal Nursing• National Perinatal Association• United States Breastfeeding Committee• United States Institute for Kangaroo Care /

Obj. 2: Identify how the evidence behind KC becomes National Guidelines for practice• Evidenced-based practice is mandated• Evidence of positive benefits of KC has been shown through

research• There have been many Cochrane Reviews of positive KC benefits.

Cochrane Reviews are the “Gold Standard “ for guiding practice• Evidence is graded “A” through “E” by the US Preventive Services

Task Force• Evidence for KC’s effects is predominantly “A”•National Professional organizations publish guidelines/

protocols /policy to guide institutional adoption of national recommendations • Institution-specific policies reflecting national recommendations

are developed and implemented

Table of National Recommendations

In the syllabus that you will print to bring with you to the KC course you will find a “Table of Recommendations for KC” that is several pages long. It is too extensive to put in this power point. It will be useful to you as reference when you are implementing KC in your institution. If there is a guideline written it means that the evidence has been established for the specific benefit of KC you are interested in; i.e. breastfeeding the full term infant or diminishing pain in the preterm infant in the NICU.This is the title page of the handout in your syllabus materials2016 USIKC Table of National Guidelines and Recommendations (Ludington-Hoe & Morgan)

Obj. 3: To review latest recommendations for KC•Boundy, et al. Kangaroo Mother Care and Neonatal Outcomes:

a Meta-analysis. 2015 Pediatrics. 137 (1):e20152238. •KMC infants: 36% lower mortality among low birth weight

newborns• decreased risk of neonatal sepsis, hypothermia,

hypoglycemia, and hospital readmission• increased exclusive breastfeeding. •Newborns receiving KMC had lower mean respiratory rate and

pain measures and higher oxygen saturation, temperature, and head circumference growth. Conclusion :“Interventions to scale up KMC implementation are warranted”. Not a Cochrane Meta-analysis

Obj.3. American Academy of Pediatrics

• Baley J and Committee on Fetus and Newborn.(2015-Augst 31). Skin-to-Skin Care for Term and Preterm Infants in the Neonatal ICU. Pediatrics, 136(3):596-599 .doi:10.1542/peds.2015-2335 pii: peds.2015-2335

• “Because SSC has been shown to be feasible and safe in the NICU in infants as young as 26 weeks’ gestations (cites Bier et al., 1996), with benefits for both parents and infants, FACILITIES ARE ENCOURAGED TO OFFER THIS CARE WHEN POSSIBLE.”(PG 598).”

• “It has been shown that skin to skin care results in improved breast feeding, milk production, parental satisfaction and bonding”(pg. 598).

• Other effects associated with KC: decreased pain, improved sleep, decreased stress, more alert, decreased crying, better Bayley scores at 6 and 12 months and at 10 years

Reducing and Preventing Pain From Bedside Care Procedures

Pediatrics committee on Fetus and Newborn and Section on Anesthesiology and Pain Medicine “ Prevention and management of procedural pain: An Update” Pediatrics 2016;DOI: 10.1542/peds.2015-4271Kangaroo Care is

recommended as a non-pharmacological method of pain reduction and/or elimination

What is this infant thinking?

Note the tourniquet

Are you using Kangaroo Care to prevent or minimize pain for

your preterm infants?

American Heart Association &

American Academy of PediatricsZaichkin, J., & Weiner, GM. (2011). Neonatal

Resuscitation Program (NRP) 2011: New Science, New Strategies. Neonatal Network 30(1), 5-13. ”If the newborn is term, breathing, and has good muscle tone, the baby SHOULD STAY with his mother for routine care. This includes the vigorous infants with meconium-stained fluid” Page 10 There is 2015 update. 7th update effective Jan 2017; I have only seen 2 pg newsletter for resuscitation of depressed infant

Delivery RoomGuidelines for healthy, vigorous infant recommend Kangaroo Care immediately after delivery (NRP 2011)

Obj. 3: National Perinatal Association

Hynan MT, Hall SL. 2015. Psychosocial program standards for NICU parents. J Perinatol.35 : supplement 1-4. doi: 10.1038/jp.2015.141.

Provides a rationale for and brief description of the process of developing recommendations for program standards for psychosocial support of parents with babies in the neonatal intensive care unit (NICU).•“early, frequent and prolonged skin-to-skin contact as is medically appropriate” (supports parents’ roles as primary caregiver)•“Skin-to-skin care to provide neuroprotection of their babies”

National Perinatal AssociationMultidisciplinary Guidelines for the Care of

Late Preterm Infants: A Collaborative Kangaroo Care is mentioned throughout the document for “In-Hospital Care” of late preterm

• Stabilization after birth• Reducing risk of respiratory distress• Reducing risks of hypothermia• First breastfeeding

Access at: http://nationalperinatal.org/latepreterm

Review of Family Centered Developmental Care (FCDC)

recommendations- Natl Perinatal AssocCraig et al. 2015.Recommendations for involving family in developmental care of the NICU infant. J of Perinatology 35, S5-S8;doi:10.1038/jp.2015.142

• Separation of parents from NICU babies results in adverse outcomes for baby’s social, emotional development, and behavioral and cognitive functioning. • Stress in NICU results in change in brain structure and function• Support parents as primary caregivers and integral part of

NICU team• Early, frequent and prolonged skin-to-skin contact as

medically appropriate• Kangaroo Care is component of Developmental Care which

includes parents

Recommendations for Neuroprotective Care of Preterm

infants Seven components of Neuroprotective care•Healing Environment• Partnering with families• Positioning and handling• Safeguarding sleep•Minimizing stress and pain• Protecting skin •Optimizing nutrition

Altimier LB. 2015. Neuroprotective Core Measurre 1: The Healing Environment. Newborn & Infant Nursing Reviews .15pg 91-96

Altimier LB. 2015. Neuroprotective Core Measurre 1: The Healing Environment. Newborn & Infant Nursing Reviews .

15pg 91-96 (continued)Kangaroo Care is Optimal care for the preterm infant; it provides:• Thermosynchrony• Fulfills need for touch•Needed proprioceptive sensory input to developing

brain (pg93)

Recommended interventions for neuroprotective / neurosupportive care for the tactile system include:•“Facilitate early, frequent, and prolonged skin-to-skin contact”(p93)

Obj. 3: World Health OrganizationPregnancy, Childbirth, Postpartum and Newborn

Care: A Guide for Essential Practice (Revised 2015)

•Place baby on abdomen in mother’s arms in skin-to-skin (pg D11)•Keep the baby warm in skin-to-skin care with mother (pg D19)•Monitor mother at 1,3, and4 hours; then every 4 hours•Keep mother and infant together•Never leave mother and infant alone

Obj.4. To discuss how Kangaroo Care can help your institution to achieve

Baby Friendly Status•World Health Organization•10 Steps to Baby Friendly Status•Step 4. Help mothers initiate breastfeeding within a half-hour of birth (pgs 31-39)•Reviews many studies related to successful breast feeding•Many recommendations for “early skin contact” to promote successful breastfeeding

Healthy People 2020Access @ http://www.healthypeople.gov/

Every 10 years this organization produces a national health promotion and disease prevention initiative bringing together many individuals and agencies to improve the health of all Americans ; etc

The following slide notes the Healthy People 2020 initiatives related to breastfeeding (BF)Kangaroo Care has been identified by many organizations to initiate, promote, and maintain exclusive BFThus KC helps to achieve Healthy People Goal of increased number of infants who are BF

MICH-21:  Increase the proportion of infants who are breastfed MICH-21.1 Ever 81.9%MICH-21.2 At 6 months 60.6%MICH-21.3 At 1 year 34.1%

MICH-21.4 Exclusively through 3 months 46.2%

MICH-21.5 Exclusively through 6 months 25.5%

MICH-22:  Increase the proportion of employers that have work site lactation support programs. 38%

MICH-23: Reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life.

14.2%

MICH-24: Increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies.

8.1%

Healthy People 2020 Objectives

Obj.5. To identify recommendations of the Center for Disease Control and Prevention (CDCP) for KC to increase exclusive breast milk feedingsHealthy People produce health goals for the nation every ten years. The previous slide shows that a national goal is to increase exclusive breast milk feeds.To assist in the achievement of this goal, in 2007 the CDCP developed a “survey” for hospitals to complete every two years. It is called the “mPINC Survey”

Introduction to mPINC• In U.S., most infants born in hospital or free-standing

birth center. • Typically stay is short, but events during this time have

lasting effects.•Many experiences of mothers and newborns in the

hospital affect breastfeeding.(BF)• These experiences reflect routine practices at the

facility; patients rarely request care different from that offered them by health professionals.• Experiences with BF in the first hours and days of life

significantly influence an infant’s later feeding. •Due to the relationship with the birth experience, BF

must be established during maternity hospital stay.• The mPINC looks at these practices and scores the

facility on the “Report Card”. This report identifies areas which need improvement and areas of excellence pertaining to successful BF

mPINC (2007 ) CDCP National Survey of Maternity Care Practices in Infant Nutrition

and CareWho participates in the mPINC survey? All hospitals with maternity services and all free-standing birth centers in the US are invited to participate in CDC’s mPINC survey every two years.

The survey produces a “report card” for each stateThis report summarizes results from all Ohio facilities* that participated in the 2015 mPINC Survey and identifies opportunities to improve mother-baby care at hospitals and birth centers and related health outcomes throughout Ohio. (*Sample Report Card for Ohio in your syllabus)

Access mPINC report card for your state, city and hospital at:

http://www.cdc/gov/breastfeeding/data/reportcard.htm

mPINC (2007 )Areas assessed with the mPINC survey(this is only a few of areas assessed)

L & D Care

•Initial skin-to-skin contact (Note the very first area assessed)•Initial breastfeeding opportunity•Routine procedures performed in skin-to-skin

Post-partum

Care

Feeding of Breastfed Infants

•Initial feeding received after birth•Supplementary feedings

Breastfeeding Assistance

•Documentation of feeding decision•Breastfeeding advise and counseling•Assessment & observation of breastfeeding•Pacifier use

Contact Between Mother and

InfantShould be

sustained by:

• No separation of mother and newborn during transition to receiving patient care units

• Infant rooms in with mother 24/7• Minimize mother infant separation

throughout the intrapartum stay• Encourages transfer to PP in

Kangaroo Care

Conclusions of the CDCPafter 2007 mPINC National Results

• Steady increase in exclusivity at 3 and at 6 months

• < 5% of US births occur in Baby Friendly hospitals

• “Maternity practices in US hospitals and birth centers must be changed to improve breastfeeding, thereby helping to improve maternal and child health” [MMWR 2008; 57(23):621-625].

How can we use the mPINC report card

•The mPINC identifies your institution’s strengths and weaknesses related to breastfeeding (BF) and includes the practice of Kangaroo Care (KC)•Results can be used to guide Quality Improvement projects within your clinical areas•Can help you to improve all areas of BF: initiation, duration, and exclusivity •Can provide you with information for education of parents and staff from birth through discharge, which includes KC, related to BF (see next slide)

Skin-to-skin contact–Doctors and midwives place newborns skin-to-skin with their mothers immediately after birth, with no bedding or clothing between them, allowing enough uninterrupted time (at least 30 minutes) for mother and baby to start breastfeeding well.

Teaching about breastfeeding–Hospital staff teach mothers and babies how to breastfeed and to recognize and respond to important feeding cues. Early and frequent breastfeeding- Hospital staff help mothers and babies start breastfeeding as soon as possible after birth, with many opportunities to practice throughout the hospital stay. Pacifiers are saved for medical procedures. http://www.cdc.gov/breastfeeding/pdf/mPINC/Maternity_Care_Practices.pdf

What hospitals Can do…

I

Implement Evidenced-Based Supportive

Hospital Practices (CDC 2011)

Using the mPINC to improve BF Exclusive breastfeeding –Hospital staff only disrupt breastfeeding with supplementary

feedings in cases of rare medical complications.

Rooming-in –Hospital staff encourage mothers and babies to room together

and teach families the benefits of this kind of close contact, including better quality and quantity of sleep for both and more opportunities to practice breastfeeding.

Active follow-up after discharge –Hospital staff schedule in-person breastfeeding follow-up visits

for mothers and babies after they go home to check-up on breastfeeding, help resolve any feeding problems, and connect families to community breastfeeding resources

Crenshaw J. 2007. Care Practice # 6: No separation of mother and baby, with unlimited opportunities for breastfeeding. J Perinatal Education. 16(3)39-43

• Hospitals need to do more to support BF families.

• Hospitals can participate in the Maternity Practices in Infant Nutrition and Care (mPINC) survey, and use their results to improve maternity care practices.” All past performances on Breastfeeding report cards can be accessed

How can states use Report Card to improve BF rates?• To access your state mPINC results log on to: • http://www.cdc.gov/breastfeeding/

data/mpinc/results.htm

mPINC Report Card is in 8th Year

Academy of Breastfeeding Medicine Protocol Committee. 2010. ABM Clinical Protocol #7: Model breastfeeding policy (Revision 2010). Breastfeeding Medicine, 5(4), 173-177.Academy of Breastfeeding

Medicine 2010Protocol #7: “At birth or soon thereafter all newborns, if baby and mother are stable, will be placed skin-to-skin with the mother. Skin-to-skin contact involves placing the naked baby prone on the mother’s chest. The infant and mother can then be dried and remain together in this position with warm blankets covering them as appropriate… Vitamin K and prophylactic antibiotics to prevent opthalmia neonatorum should be delayed for the 1st hour after birth to allow uninterrupted mother-infant contact and breastfeeding.” (pg. 173)“After 24 hours of life,….. skin-to-skin contact will be encouraged.” (pg. 175)

Academy of Breastfeeding Medicine. (2010). Non-pharmacologic management of procedure-

related pain in the breastfeeding infant. Breastfeeding Medicine 5(6), 1-5. DOI:

10.1089/bfm.2010.9978. *Protocol #23: “Coordinating a breastfeeding session

with the timing of the (painful) procedure is best, but, if this is not possible, skin-to-skin contact can comfort infants undergoing a procedure such as heel lance. Skin- to-skin contact also gives the mother a caretaking role during the procedure that is unobtrusive, and by diminishing infant stress, it can increase maternal confidence as to her value to the infant. ..Sucrose and pacifier can both be combined with the skin-to-skin component of parental contact” (Pg. 1). “Skin-to-skin contact provides effective pain reduction for premature infants.”(Pg. 2)….

International Network for Kangaroo Care (INK) 2000•Wrote the Bogota Declaration “Kangaroo Mother Care is a basic right of the newborn, and should be an integral part of the low birth weight and full-term newborn’s care, in all settings, at all levels of care, and in all countries”.

•Charpak,N, deCalume, CF, Ruiz JG 2000. The Bogota Declaration on Kangaroo Mother Care: conclusions of the second international workshop on the methods. Acta Pediatrica. 89(9); 1137-1140

United States Institute for Kangaroo Care

Supports and recommends the Bogota Declaration

There are many protocols and recommendations for the use of

Kangaroo Care•Are your staff prepared to

implement KC safely?•Are your patients/ clients ready to

implement KC? •Have they been prepared?•Does this mean that your

institution is ready to implement Kangaroo Care as a standard of care?•How do you know if you are ready

and how do you get ready for KC?

Components of Readiness…what they

need to have and to know•Institutional Readiness•Staff Readiness •Parental Readiness •Patient Readiness

Assessment of Institutional Readiness

• Includes physical, human, and educational resources.• Is their physical space and chairs for KC• Is their adequate nursing staff? •Has staff been educated about benefits of, and skills for KC. Standardized basic education r/t KC is essential•Do you have educational material for parents?•Do you have written policies pertaining to KC?•Are physicians (NEOs, OBs, NNPs) supportive?

Assessment of Parental Readiness for KC•Are parents aware of KC and its’ benefits?•Are the parents asking to hold their infant in KC? •Are they ready to provide KC physically? •Are they ready emotionally?•Have they been given adequate information to make informed consent to provide KC

Assessment of Staff Readiness

*Has staff received adequate training to offer KC safely?*Do they know all of the benefits of KC for full term and preterm infants?*Do they have support system for questions? *Do they have needed policies ?*Are they competent in the practice of KC?*Are they competent in the assessment of the infant while in KC?

Summary*As you have learned, there are many

recommendations for Kangaroo Care for both full term and preterm infants. *Having these guidelines does not mean that

you are ready to implement KC for your clinical are.*Knowing these guidelines is the first step in

implementing KC.*It takes team work, education, and commitment

from all; doctors, RNs, NNPs, OB GYNs, along with administrative support.

Final WordsThe Bogota Declaration is complete and concise. It states: “Kangaroo Mother Care is a basic right of the newborn, and should be an integral part of the low birth weight and full-term newborn’s care, in all settings, at all levels of care, and in all countries”.It is our responsibility as health care providers for mothers and infants to educate ourselves so that we may safely assure that this basic right is protected forand provided for all newborns