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Results Background Results Clinical Relevance Purpose Methods Physiologic Stability of Intubated Preterm Infants Receiving Kangaroo Care in the Neonatal Intensive Care Unit: A Systematic Review Maggie Holland, SPT, Courtney Matthews, SPT, Anne McGinty, SPT, Meredith Ramsey, SPT, Adam Goode, PT, DPT, PhD, Leila Ledbetter, MLIS & Laura Case, PT, DPT, MS, PCS, C/NDT Doctor of Physical Therapy Division, Duke University, Durham, NC and Duke University Medical Center Library, Durham, NC Conclusions Kangaroo care or skin-to-skin care (SSC) has been shown to be beneficial for stable preterm infants. Benefits of this intervention include reduced mortality, increased growth, enhanced parent-child bonding, and decreased length of hospital stay. SSC has been used with less stable infants, but SSC with very premature mechanically ventilated infants remains controversial. Review the effect of SSC on measures of physiologic stability and report any potentially destabilizing events in premature mechanically ventilated infants A librarian-assisted computerized search of databases was performed including: PubMed, Cumulative Index to Nursing Allied Health Literature (CINAHL), and EMBASE. Data was abstracted and qualitatively synthesized to assess: • SSC procedure • Outcomes of physiologic stability • Destabilizing events – accidental extubation, apnea, and hypothermia Physiologic stability may be maintained or improved during SSC in some preterm infants on ventilators though with less stability reported in infants <1000 to 1200g. The highest-level study design showed increased temperature variability and FiO2 demand during SSC, reinforcing the need for continuous monitoring of individual infant response. Continued research is needed especially randomized controlled trials. SSC may be safely included in developmental care for some intubated, preterm infants with careful monitoring of physiologic stability and avoidance of increase in distress. Physical therapists can contribute to the NICU multidisciplinary team in providing safe transfers, positioning, support, and monitoring during SSC. Author, Year Study Design Population Azevedo, 2011 Quasi -experimental 43 infants, GA 29.1 wks, mean wt. 1096g Carbasse, 2013 Prospective cohort 96 infants, mean GA 28 wks, mean wt. 1069g Clifford, 2001 Case series Charts of 7 infants, mean GA 25.5 wks, mean wt. 752g Gale, 1993 Case series 25 infants, mean GA 30.5 wks, mean wt. 1100g Karlsson, 2012 Cohort design 26 infants, GA range 22-26 wks, mean wt. 600g Neu, 2000 Crossover design 15 infants, mean GA 30.2 wks, mean wt. 1094g Parker, 2002 Case study 1 female infant, born 27 wks GA, 917g Smith, 2001/2003 Crossover design 14 infants, mean GA 25.7 wks, mean wt. 990g Swinth, 2003 Case study 1 female infant, 33 wks GA, 2024g Van Zantan, 2007 Case control with repeated measures Group 1: 18 infants, GA <28 wks, mean wt. 834g Group 2: 16 infants, GA 28-30 wks, mean wt. 1244g Level of Evidence: GRADE C 0 1 2 3 4 5 6 7 8 9 Heart Rate Oxygen Saturation Fi02 Temperature Number of Studies Physiologic Variable Summary of Stability Conclusions Maintain Stability Improve Stability Decrease Stability Articles identified through database searching (n = 174) Articles after duplicates removed (n = 115) Title/Abstract screened (n = 115) Articles excluded (n = 67) Full-text articles assessed for eligibility (n = 48) Full-text articles excluded (n = 37) Exclusion Reasons: • Not mechanically ventilated • SSC not primary intervention • Infants not premature (gestational age (GA) >37 wks) • Outcome doesn’t measure stability • Only abstract available • Commentaries/recommenda tions • Not in English Studies included in synthesis (n = 11) Screening Included Eligibility Identificatio n Author, Year Potentially Destabilizing Events Carbasse, 2013 Apnea or bradycardia in 13% of SSC episodes, no extubations Clifford, 2001 1 accidental extubation during transfer due to loose endotracheal tube Gale, 1993 1 accidental extubation during SSC Karlsson, 2012 1 episode of hypothermic event due to failure of ventilator gas humidifier/warmer Smith, 2001/2003 1 accidental extubation on a washout day (not during SSC) None of these events required termination of SSC. Description of Included Studies Potentially Destabilizing Events References Range of Data from Key Outcomes Outcome Normal Range Studies Reporting Outcome Range of Data Values During SSC Heart rate 120-180 bpm 5 • Max variation ranged from -3.5 bpm to +7.8 bpm O2 saturation adjust FiO2 if SaO2 or SpO2 <85% or >96% 9 • 0.19% increase – 1.46% increase • 1.3-2.5% decrease during transfer which increased to normal within 1 min. • 1 study reports more desaturation after 20 min. if infant <1.2kg • 1 study reports greater decrease in supplemental O2 needs for intubated vs. non-intubated infants FiO2 adjust FiO2 if SaO2 or SpO2 <85% or >96% 4 • 5.36% decrease – 4% increase • Only 1 study reports increased FiO2 during SSC, greater increase in the second hour Temperature 36.5 – 37.5 °C 9 • 0.29°C decrease – 0.2°C increase in axillary temperature (n=4) • 1 study showed increased peripheral temperature leading to 0.8°C change in central-peripheral temp. • 4 studies show statistically significant change • More change in infants <1000g The most variation for all variables occurred during the transfer and then quickly stabilized. 1. Azevedo, Vívian Mara Gonçalves de Oliveira, César Coelho Xavier, and Fernanda de Oliveira Gontijo. “Safety of Kangaroo Mother Care in Intubated Neonates under 1500 G.” Journal of Tropical Pediatrics 58, no. 1 (February 2012): 38–42. doi:10.1093/tropej/fmr033. 2. Bohnhorst, Bettina. “Skin to Skin Care in the Neonatal Intensive Care Unit: More Data Regarding Seriously Ill Infants Are Badly Needed.” Neonatology 97, no. 4 (2010): 318–20. doi:10.1159/000255164. 3. Carbasse, Aurélia, Sylvie Kracher, Martine Hausser, Claire Langlet, Benoît Escande, Lionel Donato, Dominique Astruc, and Pierre Kuhn. “Safety and Effectiveness of Skin-to-Skin Contact in the NICU to Support Neurodevelopment in Vulnerable Preterm Infants.” The Journal of Perinatal & Neonatal Nursing 27, no. 3 (September 2013): 255–62. doi:10.1097/JPN.0b013e31829dc349. 4. Conde-Agudelo, Agustin, and José L. Díaz-Rossello. “Kangaroo Mother Care to Reduce Morbidity and Mortality in Low Birthweight Infants.” The Cochrane Database of Systematic Reviews 4 (2014): CD002771. doi:10.1002/14651858.CD002771.pub3. 5. Karlsson, Victoria, Ann-Britt Heinemann, Gunnar Sjörs, Kerstin Hedberg Nykvist, and Johan Agren. “Early Skin-to-Skin Care in Extremely Preterm Infants: Thermal Balance and Care Environment.” The Journal of Pediatrics 161, no. 3 (September 2012): 422–26. doi:10.1016/j.jpeds.2012.02.034.
