Kangaroo Care (KC) has wide ranging physiological, and behavioural benefits for all babies and is highly therapeutic for preterm and unwell babies. It enhances physiological and thermal stability, improves growth and development, reduces stress and crying, promotes parent-infant attachment and is associated with earlier attainment and longer duration of breastfeeding. This guideline aims to assist in the facilitation of Kangaroo Care as routine care for babies who meet eligibility criteria in Special Care Nursery, the Maternity Unit and the Paediatric Unit.

Early, unrestricted and frequent Kangaroo Care will be routine practice for babies who meet eligibility criteria.

Staff will assist parents to provide Kangaroo Care with confidence.

KC - Kangaroo Care: the practice of holding a baby in skin-to-skin contact, upright between the breasts on a parent's bare chest, dressed in only a nappy and covered in a wrap.

SSC - Skin-to-skin contact

CPAP - Continuous Positive Airway Pressure

NGT - Nasogastric tube

SCN - Special Care Nursery

PNW - Postnatal ward

All staff providing care to babies within Special Care Nursery, Maternity Unit and the Paediatric Unit.

This guideline primarily outlines the practice of intermittent Kangaroo Care. Continuous Kangaroo Care may also be practiced when parents are willing and able to do this, assuming eligibility criteria for the baby are met.

1. Assessment of baby's readiness for KC

1.1 Inclusion criteria

• Stable baby (including stable on CPAP - with medical approval).

• No deterioration within prior 24 hours.

• Parents are willing to do KC.

1.2 Absolute Contraindications

• Unstable or very sick newborn.

• Mechanical ventilation for acute illness.

• Intercostal catheter.

1.3 Relative contraindications - discuss with medical team and senior nursing staff first.

• Jaundice close to exchange transfusion levels.

• First week after major surgery.

• If CPAP ceased, commence or resume KC when baby assessed to be stable.

• Episodes of apnoea, bradycardia or desaturation with handling, or prolonged recovery time.

• Treatment with vasopressor drugs, dopamine or dopamine infusion.

• Umbilical venous catheter, central line e.g. long line

• Parents with active lesions, respiratory illness, rashes. If lesions/rash can be covered and face mask is worn, KC may be possible.

1.4 KC for babies receiving phototherapy

• Maximum period is around 1 hour per episode, including feeding time.

2.0 Preparation for KC

2.1 Preparation of Parents

• Discuss benefits of KC with parents. Provide a copy of Kangaroo Care: A guide for parents CID0099 if required (See Appendix 1)

• Show parents laminated poster on wall next to cot in SCN or on cot in PNW, demonstrating correct KC positioning.( See Appendix 2)

• If mother is currently taking narcotic analgesia or methadone, advise that curtains must remain open during KC.

• Advise parent to

  • go to the toilet first if needed, have a drink and have a water bottle close by.

  • take prescribed pain relief medication if required.

  • wear a front opening top or clothing that allows easy access to their chest. A front opening hospital gown can be used. Mother should remove bra to increase skin-to-skin contact.

  • minimise distracting use of phones and electronic devices. Advise that noisy devices in close proximity to baby may cause overstimulation.

2.2 Timing of Kangaroo Care

• KC can occur at any time that is suitable for parent and baby as long as above criteria are met.

• Plan with parents for periods of KC - ideally at least 1 hour if possible, to enable baby to complete 1 sleep cycle and to reduce any stress associated with transfer.

• There is no limit as to how often and how long KC can be provided. However, re-consider frequency and timing if baby is not tolerating frequent or prolonged periods of KC. (Refer to section 3.3.1 for signs of infant stress).

• KC can continue during and after feeds. Breastfeeding, expressing, bottle feeding, finger feeding and NGT feeds are all possible during KC, with modified positioning to facilitate feeding as required.

• Do not interrupt KC unless there is a need for medical or nursing care. If interrupted, resume as soon as able.

• KC should be avoided immediately after the parent has had a cigarette. If parent is smoking, a separate jacket should be worn and removed before doing KC. Support parents with anti-smoking efforts.

2.3 Equipment

• Recliner or bed or armchair and footstool - footstool must be moved away from in front of chair during transfer

• KC wrap (abdominal tubigrip is supplied) and blankets

• Combine or padded dressing to prevent pressure from cord clamp against baby's abdomen if required

• Optional - small hand held mirror

• Optional - hat for baby only if there are concerns about thermoregulation

• Optional - pillow

• Front opening shirt/jumper/gown for the parent is useful

• Tape to secure tubing if necessary

• Ensure call buzzer is available

2.4 Preparation and Transfer (primarily for a preterm or unwell baby)

2.4.1 Prior to transfer:

• Perform any necessary procedures first and allow baby to recover and settle before transfer.

• Measure and record vital signs.

• Remove clothing, leaving only nappy on. Apply hat only if thermoregulation is a concern.

• If cord clamp is still in-situ, place combine or padded dressing between cord clamp and baby's abdomen to prevent pressure injury. Alternatively, ensure the clamp is sitting on the outside of the nappy, not pressing into the abdomen.

• Ensure all lines and tubes are well secured, gathered, free to move and reach to the chair.

• Gently place baby in supine position, maintaining containment.

2.4.2 Transfer

• Transfer is potentially stressful for the baby. Ask for help from another staff member, especially if lines are in situ.

• Explain to the parent how the transfer will take place.

• Parents must have assistance from a nurse/midwife when removing baby from an isolette. Once in an open cot, parents may be able to transfer baby independently.

• Gently touch and talk to the baby before commencing.

• Transfer should be smooth, calm and as brief as possible.

• Gently move baby from horizontal to vertical.

• Maintain containment with baby's arms and legs in the midline during transfer.

The type of transfer depends on parents ability and confidence. Standing transfers have been found to be less stressful for the baby.

Standing transfer

Parent stands beside isolette/cot and lifts baby from supine position onto their chest, assisted by staff. Parent is then is guided to the chair by staff member. A second nurse/midwife can attend to and support any tubing or lines.

Seated transfer

Nurse/midwife lifts baby from the isolette/cot and across to the seated parent. A second nurse/midwife can attend to and support any tubing or lines.

Transfer for a baby on CPAP

• Two staff members must assist with transfer

• Drain any condensation in tubing first

• Tubing is draped over parent's shoulder and loosely taped to clothing

• Check nasal cannula and tubing is correctly positioned after transfer

3.0 Kangaroo Care Positioning and Monitoring

3.1 Parent's position

• Sitting or lying back comfortably, slightly reclined.

• Feet elevated on recliner or using a footstool: particularly mothers who have recently birthed to prevent Deep Vein Thrombosis.

3.2 Baby's position

• Chest to chest, upright and between breasts/nipple line.

• Hips, legs and arms in flexed 'frog-like' position.

• Ensure there is no pressure from cord clamp on baby's abdomen - see section 2.4.1

• Head turned to the side, slightly extended in a sniffing position. Parent should be able to see the baby's face easily. A hand held mirror may also assist this.

• Held in place with KC wrap up to the ear level, then enclosed with parent's shirt or hospital gown opened at the front or covered with a light blanket.

• Educate parent to observe baby's head position to ensure it does not become flexed or overextended.

3.3 Monitoring and observations during KC

Well, term babies on PNW require only routine general observation during KC. Babies in SCN and Paediatric Unit require observations as follows:

3.3.1 Baby

• Allow 15 minutes after transfer to stabilise.

• Check baby's temperature after 15 minutes if concerned about thermal regulation - e.g. baby less than 2kg. Overheating may be indicated by restlessness or tachycardia. Add or remove hat or layers of blankets as required. Continue to monitor baby's temperature every 60 minutes if indicated.

• Continue routine cardiorespiratory monitoring, pulse oximetry, temperature and vital signs as ordered.

• Adjust oxygen as required to maintain target saturations.

• Ask parent to alert staff if they are concerned about their baby during KC.

• At nursing staff discretion, curtains should be open if there are any concerns about monitoring.

• If baby is on CPAP, or mother is taking narcotic analgesia or methadone, line of sight nursing must be maintained - curtains must be left open.

If apnoea, bradycardia or oxygen desaturation occurs, assess and adjust baby's head position: the head should not be flexed or over-extended.

Discontinue KC if:

• Vital signs and oxygen saturation levels do not stabilise to normal parameters within 15 minutes of transfer or head repositioning.

• Baby shows any signs of stress e.g.

  • Colour change, mottled skin, increased oxygen requirements

  • Agitation, restlessness

  • Tachypnoea, tachycardia

  • Arching, stiffening, finger splaying, fussing and crying

3.3.2 Parent

• If mother is currently taking narcotic analgesia, curtains must remain open during KC.

• Assess parents comfort - particularly newly birthed mother for pain, discomfort.

• Call bell should be in reach of parent.

3.3.3 Equipment

• Ensure leads, tubing, connections are not underneath baby's body or pressing into baby or parent. There should be no twisting or tension on lines and tubes.

4.0 Return transfer and documentation

• Remove wraps, ensure footstool is out of the way.

• Parent can remain seated as nurse/midwife transfers baby back to isolette or cot.

• Or parent can carefully stand whilst baby is in KC and baby is returned to cot/isolette with nurse/midwife assisting.

• Staff assistance is required if baby is in isolette. Two staff are required if baby is having CPAP.

• Reposition baby comfortably and ensure all lines and tubing are correctly in place.

• Document on Nursery Care Chart or progress notes time of commencement and completion of KC and how KC was tolerated.