Clinical Guidelines (Nursing)

Skin to Skin Care for the Newborn

  • Introduction

    Intermittent skin-to-skin care is widely recognised as a beneficial component of holistic care provision for sick or preterm infants requiring hospital admission.  The benefits for the infant include increased physiological stability, longer periods of quiet sleep, improved self-regulation development, increased breast feeding incidence and duration, decreased pain perception and reduced stress and crying.  Parental benefits include enhanced parent-infant attachment with a reduction in the negative effects of having a sick or preterm infant, greater parental ability to recognise their infant’s cues, increased self-confidence, decreased parental depression and increased maternal breast milk supply.

    Aim

    The aim of this guideline is to provide all clinical staff with the benefits, criteria and procedure to effectively and safely promote and provide skin-to-skin care to infants and parents during admission.

    Definition of terms 

    • Skin-to-Skin Care (SSC): Also known as Kangaroo Care refers to the method of holding an infant in an upright and prone position, skin-to-skin, on the parent’s chest for a period of time.  Clothing or blankets are wrapped around the infant to provide a secure kangaroo-like pouch.
    • CPAP: Continuous Positive Airway Pressure, may be delivered via Single Nasal Prong, Bi-Nasal Prong, or Nasal Mask
    • ETT: Endotracheal Tube
    • Normothermia: An axillary temperature 36.5°C – 37.5°C

    Assessment

    Criteria

    Skin-to-skin care should be promoted and provided to all haemodynamically stable infants, and also offered to families of infants receiving palliative care within the NICU. 

    Contraindications

    • High Frequency Ventilation via the Sensormedics Ventiilator
    • Nitric Oxide delivery
    • Intercostal catheter insitu
    • Umblical arterial catheter insitu
    • Unrepaired surgical conditions including gastroschisis, omphalocele and myelomeningocele
    • Infants in immediate post-operative states requiring ventilation and muscle relaxation

    Considerations

    • The provision of SSC should be discussed by the medical and nursing team, at each baby’s bedside during the ward round.  As always, families should be involved in individualised care planning
    • If there are concerns over the appropriateness of providing SSC for an infant, please raise these concerns with your medical and nursing colleagues.
    • Environmental humidity does not exclude a haemodynamically stable infant from participating in SSC.  The potential increase in transepidermal water loss (TEWL) during SSC is small and transpires to marginal clinical importance.
    • Allow a minimum of 4 hours post extubation or the cessation of CPAP to assess the infant’s stabilit
    • Caution must be taken to ensure safe management of peripheral arterial lines and central venous access devices while the infant is receiving SSC.
    • An infant under droplet or airborne precautions should be nursed in a single room with the door closed prior to coming out of an incubator for SSC.
    • Parents may initiate SSC when their infant is stable, does not require respiratory support and is without IV lines.  Ensure that nursing staff are readily available to assist with gathering equipment or guiding cardiorespiratory monitoring during the transfer.

    Management

    Equipment

    • Comfortable and stable chair with arm rests and a high back
    • Pillow
    • If parents do not have a stretchy or button front top, provide a hospital gown to allow front opening
    • Blankets and infant hat
    • Tapes to secure respiratory support tubing
    • Footstool
    • Mirror
    • Provide a quiet and calm environment, close doors and curtains to ensure privacy

    Parent preparation

    • Ensure parents are educated on the benefits of SSC and the sequence of events in transferring the infant to and from their chest.
    • Discuss timing around skin-to-skin care, including recognition of infant cues
    • Advise maternal expression and bathroom breaks prior to SSC
    • Ensure drinking water is close by
    • Offer to change the top clothes for an open-front hospital gown if top or shirt not suitable.  Ideally the mother should remove her bra for optimal skin-to-skin contact.

    Infant preparation

    • Check the infant’s temperature (ensure normothermia) and place a woollen hat on the infant’s head if low birth weight, or previous temperature instability
    • Ensure infant is nursed only in a nappy
    • Confirm patient monitoring alarms are of appropriate limits and audible
    • Ensure patency and security of intravenous lines and gavage tubes
    • If the infant is intubated, ensure the ETT is secure, check that breath sounds are equal and if required, suction the ETT prior to transfer.
    • If the infant usually requires an increase in oxygen during periods of handling, increase prior to initiating the transfer
    • Notify medical staff of SSC timing if there were concerns over the infant’s stability
    • Drain condensation from respiratory support tubing prior to moving the infan
    • Place the chair close to the ventilator and infusion pumps, and ensure that all respiratory support tubing, lines and monitoring cables will easily reach the chair prior to transfe
    • Disconnect skin temperature probe cables and set the radiant warmer or isolette to an appropriate air temperature to maintain the correct level of ambient heat while the infant is in SSC

    Transfer

    • Should staff feel uncomfortable with the provision of skin-to-skin care, they must enlist the assistance of an experienced nurse.  At least two nurses must be present for the transfer of a ventilated infant into SSC.
    • Gently rouse the infant prior to initiating transfer or handling and respond to any cues of distress with containment.  Ensure that the handling required to move the infant from a horizontal to vertical position is slow and controlled.
    • Support all respiratory support tubing, intravenous infusions, gavage tubing and monitoring cables during transfer
    • Transfer the infant from the cot to the parent’s chest in a smooth and steady movement. Position the infant comfortably upright and prone with their legs and arms flexed and their head to one side.  Have the parent support the infant with one hand on the infants’ head and the other over the infant’s bottom
    • If the infant is on CPAP ensure prong or mask position is appropriate to not place additional pressure on the nares or septum and that the ventilator is delivering the correct pressure
    • If the infant is ventilated, ensure the ETT remains secure and without additional tension and that the ventilator is delivering the correct pressure
    • Secure respiratory support tubing by taping to the parents clothing at shoulder height, allowing for some movement of tubing as the baby moves their head.  The tubing can then pass over the back corner of the chair
    • Ensure infusion lines, gavage tubes and monitoring leads remain free from tension
    • Wrap the parent’s shirt or gown around the infant to form the “pouch” and place a blanket over the infant’s back.

    During skin-to-skin care

    • If the infant is receiving respiratory support, the nurse should remain in the room for the duration of skin-to-skin care and regular assessments should be performed 
    • Allow the infant time to settle into SSC.  Adjust oxygen as required, allowing for a 10% increase.  Ensure good head position is maintained and suction the airway as indicated.  If the oxygen requirement remains increased by greater than 10% despite the above interventions, the infant is displaying signs that they are not tolerating the procedure and should be returned to the cot.  Notify medical staff and ensure that the parents understand why SSC was ceased on this occasion.
    • Check the infant’s axillary temperature after 15 minutes of SSC, add or remove hats or blankets as required and continue to monito
    • A mirror should be provided to allow the parents to see their infant’s face during SSC.  Encourage parents to quietly talk, hum or sing to their infant.
    • Feeding via gavage tube should continue, ensuring that at least 20 minutes passes after completion of the feed before further transfer.  If the infant is on continuous feeds, pause the infusion during transfers and restart after 10 minutes.
    • Preterm infants less than 32 weeks corrected gestation are not yet able to coordinate effective breastfeeding, however if they are showing signs of interest in sucking, they may ‘nuzzle’ or suck non-nutritively on an empty breast.
    • If infants greater than 32 weeks corrected gestation are not requiring CPAP or ventilation, and are awake and alert during SSC, a breastfeed may be offered.  Assess signs of readiness to feed, and discuss with the infant’s mother regarding rate of milk flow and breast fullness.  Adjustments should be made according to the infant’s ability and stage of feeding.

    Completing skin-to-skin care

    • SSC should last at least 45 minutes; and if comfort, stability and contentment are evident for both the infant and the parent, it can be continued for 2-3 hours.  Monitor the infant’s cues of restlessness as an indication that they wish to return to their cot.  
    • As with the transfer into SSC, ensure sufficient staff are present, and that the infant and tubing, lines and cables are safely supported during the transfer back into the cot.
    • Reattach temperature probes and record an axillary temperature 15 minutes after returning to the cot.  Reengage servo control functions if the infant was previously requiring this thermoregulatory mode
    • Encourage maternal expression after she has partaken in SSC, as a larger volume of milk may be obtained post SS
    • Document the time and duration that the infant participated in SSC, and the relevant observations and assessments during it.

    Evidence table

    The evidence table for this guideline can be viewed here

    References

    • Auckland District Health Board Newborn Services Clinical Guideline (2007) ‘Kangaroo Care’.
    • DiMenna, L (2006) ‘Considerations for Implementation of a Neonatal Kangaroo Care Protocol’, Neonatal Network, 25(6):405-412.
    • Dodd, V (2004), ‘Implications of Kangaroo Care for Growth and Development in Preterm Infants’, Journal of Obstetric, Gynecologic and Neonatal Nursing, 34(2): 218-232.
    • Franck, L, Bernal, H & Gale, G (2002), ‘Infant Holding Policies and Practices in Neonatal Units’, Neonatal Network, 21(2): 13-20.
    • Hunt, F (2008), ‘The Importance of Kangaroo Care on Infant Oxygen Saturations Levels and Bonding’, Journal of Neonatal Nursing, 14(1): 47-51.
    • Karlsson, V, Heinemann, A, Sjors, G, Hedberg Nykvist, K & Agren, J (2012), ‘Early Skin-to-Skin Care in Extremely Preterm Infants: Thermal Balance and Care Environment’, Journal of Pediatrics, 161(3): 422-426.
    • Kledzik, T (2005), ‘Holding the Very Low Birth Weight Infant: Skin-to-Skin Techniques’, Neonatal Network, 24(1): 7-14.
    • Ludington-Hoe, A, Ferreira, C, Swinth, J & Ceccardi, J (2006), ‘Safe Criteria and Procedure for Kangaroo Care With Intubated Preterm Infants’, Journal of Obstetric, Gynecologic and Neonatal Nursing, 32(5): 579-588.
    • Managan, S & Mosher, S (2012), ‘Challenges to Skin-to-Skin Kangaroo Care: Cesarean Delivery and Critically Ill NICU Patients’, Neonatal Network, 31(4): 259-261.
    • Roller, C (2003), ‘Getting to Know You: Mothers’ Experiences of Kangaroo Care’, Journal of Obstetric, Gynecologic and Neonatal Nursing, 34(2): 210-217.
    • Royal Women’s Hospital Clinical Guideline (2nd January 2015), ‘Kangaroo Care’.

    Disclaimer

    Please remember to read the disclaimer

     

    The development of this nursing guideline was coordinated by Tara Doyle, Associate Nurse Unit Manager,Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated June 2016.