Close to the Heart

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July 2003

By C.A. Wolski

Lori Ganz, OTR, BCP, assists the mother of a premature infant in the practice of kangaroo, or skin-to-skin, care.

The name may sound odd, but “kangaroo care,” also known as skin-to-skin care, is a very real way in which some occupational therapists are aiding premature infants. The therapy, which requires no equipment or special budget line items, has been shown to have benefits for both the child and the parent, and may help stave off long-term developmental problems as well.

Originated in 1983 in Bogota, Colombia, by physicians Neos Edgar Rey and Hector Martinez, kangaroo care was a product of sheer necessity. The country had a severe shortage of incubators, and this method—which imitates the Australian marsupial’s method of incubating its joey—was a commonsense solution to the problem.

A SOFT, WARM PLACE

The care protocol of this kind of therapy is simple. The baby, clad only in a diaper and cap, is placed on the mother’s or father’s bare chest. The theory is that this skin-to-skin contact has the same effect as an incubator, allowing the baby to maintain its temperature and gain weight. And though grounded in necessity and common sense, the practice has a scientific basis.

In the beginning of kangaroo care, practitioners quickly observed that “babies who had skin-to-skin care apparently were thriving better or faster, and gaining weight,” says Jose Adams, MD, director of neonatology at Mt Sinai Medical Center, Miami Beach, Fla, who began prescribing kangaroo care at the 13-bed neonatal intensive care unit (NICU) in the early 1990s. “The observations that came about because of this type of practice were very interesting: the infants’ ability to maintain temperature, the thriving of these infants, and the fact that [hospitals] could get the infants out of intensive care and send them home sooner with the mother, because the mother could be the surrogate for the [incubator].”

Although kangaroo care is available to every child, not only premature infants, at Mt Sinai, there are criteria that have to be met. The child has to be between 2 and 3 pounds and be able to maintain its temperature. Initially, care is given for 45 minutes to 1 hour per session, which is increased as the baby becomes more stable. According to Adams, every premature baby and between 80% and 90% of full-term infants are taking part in Mt Sinai’s kangaroo care program.

Not only does kangaroo care have benefits for the child, but parents report that it has helped in nurturing the parent-child bond—and this helps promote the practice. “When we questioned the parents before and after the kangaroo care, across the board all of them were elated with the experience,” says Adams. Either parent can participate in kangaroo care.

At Mt Sinai, and in most NICUs, nurses take the lead in advocating kangaroo care, teaching parents its methods, and monitoring the practice. But kangaroo care does not have to be the exclusive territory of an NICU nurse. Occupational therapists are finding that kangaroo care can be a beneficial practice to take part in, with both short-term and long-term rewards.

THE MAGIC TOUCH

At Memorial Hospital, Colorado Springs, Colo, the OT and nursing staffs in the 45-bed NICU work closely together. The nursing staff concentrates on the immediate care of the infant, while the OT staff concern themselves with long-term outcomes, with a special emphasis on the child’s developing sensory system.

Lori Ganz, OTR, BCP, coordinator of inpatient pediatric rehabilitation at Memorial Hospital, first heard about kangaroo care in the late 1980s. She says what has fascinated her from the beginning, from a sensory motor perspective, is “the skin-to-skin portion of kangaroo care—how the tactile and olfactory systems are really enhanced, how that then helps with temperature control and breathing rates and all the things that physiologically show up in a nursery.

“As an OT, I see the babies in developmental follow-up after they have left the hospital, and over the years there have been a number of children out of the NICU who have significant sensory issues that really interfere with normal development and functional skills.” Based on Ganz’s experience, kangaroo care seems to subvert these developmental problems, which include hypo- and hyper-sensitivity.

As with Mt Sinai, at Memorial Hospital, every parent is encouraged to at least try kangaroo care. The practice is individualized for each patient, and is part of a continuum of care that includes adjunct tactile care methods such as infant massage, ongoing holding, and brushing. As Adams has found, Ganz says that kangaroo care helps with parent-child bonding, reduces stress for the parent, and reduces the potential for the child developing attachment disorders. According to Ganz, more than 50% of parents with children in Memorial Hospital’s NICU take advantage of kangaroo care.

Even though Ganz sings kangaroo care’s praises, she says there is one factor woefully lacking in making kangaroo care commonplace in every hospital, and that is research.

Mt Sinai was the site of a recent study conducted by Megan Grindstaff, MS, OTR, while she was a student at Florida International University, Miami. Her quantitative pilot study included eight infants and their parents who were using kangaroo care.

“I measured heart rate, respiration rate, and the amount of oxygen in blood for a 30-minute period on each infant for each form of care [crib or incubator and kangaroo care] after they had eaten,” she says. “During that time, I was looking at the variability of their physiological parameters. Then I introduced an alerting stimulus because I wanted to see—as a result of both forms of care—what happens to their vital signs after that stimulus, and what was the effect of each form of care on their vital signs.”

Grindstaff’s research paralleled work Adams began in the early 1990s, which measured a number of additional parameters, including cardiovascular stability, sleep apnea, and decrease in heart rate during kangaroo care. “The reason we did these kinds of studies was to find physiologic proof that there are any specific physiological changes that occur with a baby on an acute basis while performing kangaroo care,” says Adams. The study found that kangaroo care has measurable physiological responses.

In her research, Grindstaff found there are no harmful effects connected with kangaroo care. There may not be significant proven results, she says, but “there’s no reason why you shouldn’t offer it, especially if it’s going to help the parents feel more confident with their own skills and becoming more attached to their infants.” She adds that, according to the most recent figures in 1999, the therapy is still not a regular protocol in NICUs, as it is considered a matter of parental choice. In 1993, only 70 of the country’s 502 NICUs were offering kangaroo care. By 1997, this number had almost tripled with 200 NICUs offering it.

Adams is cautious about crediting kangaroo care alone with improving the status of his young charges. “What we have typically done is limit ourselves to the acute physiological changes, but other people have reported in the literature that these babies attain weight faster, and are discharged faster from the neonatal intensive care unit,” he says. “But those are very difficult things to assess and to quantify.” However, with all the apparent benefits and no recorded harm, it still is not a standard of care, says Grindstaff, citing her study.

SPREADING THE WORD

Resistance can be tied to a number of factors including a bias in favor of technology. “I think that when it was initially being talked about, there were certainly people who said, ‘We can’t do that, the baby’s too sick, the baby’s too small, they’ll get cold,’” says Ganz. “I think there’s still that reservation even today. Sometimes we push for it, and sure enough the baby does well. Occasionally, there’s a baby who doesn’t do well, but I think often it’s not because of the kangaroo care, it is [because of] other factors. “There has been concern that the baby has to be under a warmer and has to be monitored. I think it’s easy to let the technology do the work and not be convinced that the temperature regulation from the parent can do better than the machine can do,” she says.

Adams says Mt Sinai’s administration embraced the practice of kangaroo care from the beginning. There may be a tandem factor that will ultimately spread the use of kangaroo care—daily use, buttressed with scientific validation. “[Kangaroo care] is an important example of how we have adapted a no-nonsense, day-to-day activity of mothers and fathers who have been doing this for many, many years, into our daily practice and we have legitimized its use based on scientific data,” says Adams.

According to Ganz, most practitioners in NICUs have heard of kangaroo care, but it is not institutionalized as are other care protocols. However, “any therapist working in a NICU should be aware of the statistical benefits and the reasons behind it,” she says.

But awareness of kangaroo care, and promoting it as a clinical practice, are two different things. “Since we are so oriented to the sensory system, I think it’s essential that an OT be a part of promoting [kangaroo care], because it has so many benefits in the areas that we often are treating children for later on,” she says. “If we want to look at long-term sensory issues, then I think it’s essential that we look at what happens early on.”

C.A. Wolski is associate editor of Rehab Management.

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July 2003