Introduction
When a child is born, it leaves the warmth of the mother's womb and enters a new world. It is extremely important for the mother to maintain closeness with her baby. The mother's body is the only habitat the baby is accustomed to. Kangaroo mother care is performed by maintaining skin-to-skin interaction between the mother and baby. It is a universal, simple to perform method, which promotes the healthy growth of infants (Olanders, Marit. 2013). According to the World Health Organization, the benefits of kangaroo care were first reviewed in Bogota, Colombia. This healthcare intervention was developed as an alternative to receiving inadequate and insufficient incubator care. After two decades of implementation and research, it is now made clear that kangaroo care is more than an alternative to incubator care. "It has been shown to be effective for thermal control, breastfeeding and bonding in all newborn infants, irrespective of setting, weight, gestational age, and clinical conditions" (WHO, 2003). After birth, using skin-to-skin care has been associated with reduced crying, grimacing and heart rate surges in the newborn, improved mother-baby interaction, and the promotion of breastfeeding. "Incorporating kangaroo mother care before stabilization may represent the best chance of healthy survival" (Haxton, 2012 p. 227). In several studies of infants with neonatal abstinence syndrome (NAS), kangaroo care has been shown to decrease startle responses, lessen arousals and prolong sleep. In excessively crying infants, kangaroo care significantly decreases the amount of crying compared with massage. It has also been shown to decrease the response to painful procedures. Some studies indicate that the act of breastfeeding by mothers taking methadone is associated with reduced NAS scores, delayed onset of NAS and decreased need for pharmalogical treatment (Abdel-Latif, 2006).
Clinical Scenario
A nursing practice concern that I had encountered last semester involved a newborn within the special care nursery at Joseph Brant Memorial Hospital. This newborn was under special care for several weeks due to neonatal abstinence syndrome (NAS), sepsis and several other related conditions. I had spent many clinical hours within the special care nursery without seeing the mother present. The nurses in the unit were also able to confirm the mother's absence. The newborn did not receive any, perhaps minimal, skin-to-skin care with her mother. The consequences due to the lack of interaction were evident; the infant was frequently crying and shaking. The infant became soothed when being held by one of the nurses. The infant spent some time within an incubator. My research question is, "Do newborn infants suffering from health conditions (such as neonatal abstinence syndrome) experience increased health benefits and speedier recovery time receiving skin-to-skin care, compared to newborn infants not receiving skin-to-skin care?"
Using the Tanner model (2006), I had interpreted that the infant in this scenario was lacking the necessary skin-to-skin interaction. I could tell that she was suffering from drug withdrawal, as I was able to notice her physical symptoms. I responded to this situation by holding her and rocking her in my arms with the intention of providing comfort. This seemed to do so as she stopped crying and appeared more relaxed. I was really hoping that the mother would come spend some time in the nursery and provide kangaroo care. I was concerned for this infant because I had predicted that kangaroo care with the mother would have provided her with greater benefits. The infant was receiving morphine for opioid withdrawal. Perhaps the dose of morphine would have been lowered or not necessary given at all if the mother was present to provide breastfeeding. If I encounter another situation like this again, I would try to get in contact with the mother and provide her with the necessary education in providing the best care for her child.
Summary 1
My first article is called Kangaroo mother care for low birthweight infants: a randomized controlled trial in different settings by Cattaneo et al (1998). This article is a randomized control trial was carried out for the length of one year within three teaching hospitals in several countries. These countries included Ethiopia, Indonesia, and Mexico. The aim was to study the effectiveness, convenience, acceptance and cost of kangaroo mother care when compared to conventional methods of care. 149 low birthweight infants weighing between 1000-1999 grams were randomly assigned to receive kangaroo care (almost exclusive skin-to-skin contact after stabilization). 136 low birthweight infants were randomly assigned to receive conventional methods (warm blanket or incubator care). Hypothermia was significantly less common in infants receiving kangaroo care in Mexico and overall. At the time of discharge, exclusive breastfeeding was more common in the group of infants receiving kangaroo care in Mexico. This included 80% of those exclusive breastfeeding and 16% in the other group. Overall, 88% of those providing kangaroo care were exclusively breastfeeding whereas 70% of those receiving conventional methods were exclusively breastfeeding. Infants receiving kangaroo care had a higher mean daily weight of 21.3g compared to 17.7g in the conventional group. The infants receiving kangaroo care were also discharged earlier, in 13 days compared to 16 days in the conventional group. Kangaroo mother care was considered convenient and presented advantages over conventional care methods in terms of maintaining equipment. Mothers expressed a clear preference for kangaroo care and health care workers found it safe and in the best interests of the patient. Kangaroo care was less costly than the use of incubators. This study confirms that hospital kangaroo mother care for low birthweight infants is at least as effective and as safe as conventional care. The study also shows that it provides convenience in different settings, it receives positive feedback from mothers of different cultures and practices, and it is less expensive. Breastfeeding tends to be less common among low birthweight infants, and kangaroo care may bring about an increase in its application and duration. Increased breastfeeding provides additional benefits for health and growth. For hospitals in low-income countries, kangaroo care may present life-saving opportunities where resources are scarce (Cattaneo, A, et al). A major strength of this study is that it is a randomized control trial. It includes a variation of countries and cultures involved. It is significant that the preferences and acceptance of kangaroo mother care is considered in various settings. Also, other factors are included such as expenses, feasibility, and benefits to mother and infant. It successfully demonstrates that poor mothers in any country can successfully provide health to their child without hospitalization or cost. Limitations include noting three deaths within the study, but did not indicate the cause of death or which intervention this included. Another limitation is the lack of information regarding mortality rates - what is the percentage of survival rates within each group? Also, there was no indication as to whether any participants in the study were lost within the year.
Summary 2
In the article Breastfeeding rates among mothers of infants with neonatal abstinence syndrome, Elisha Wachman (2010) explains that "woman who struggle with drug addiction during pregnancy may be the most vulnerable of new mothers" (p. 159). Methadone and Buprenorphine are both opiod substitution medications, which are compatible with breastfeeding. The objective of the study is to determine breastfeeding rates among opiod-dependent women giving birth at the following baby-friendly hospital. Between July 2003 and January 2009, a retrospective review was performed of all infants at Boston Medical Center (Boston, MA) with a diagnosis of neonatal abstinence syndrome. Baseline medical information was obtained, as well as feeding information about the mother and the infant. The mother's breastfeeding eligibility was determined when being admitted. A negative urine toxicology was required, along with no elicit drug use in the third semester, and a negative HIV status. Additional eligibility criteria included >35 weeks gestational age, infant transferred from the neonatal intensive care unit to the pediatric inpatient unit, and mother taking either methadone or buprenorphine during her pregnancy to substitute opioid drug use. 276 new mothers were accounted for in the study. 40% of the mothers carried one or more psychiatric diagnoses, while 24% were taking two or more psychiatric medications. 68% of the mothers were eligible to breastfeed, and of those, 24% breastfed to some extent during their infant's hospitalization. 60% of those stopped breastfeeding after an average of 5.88 days. Breastfeeding rates among opiod-dependent women were low, with three-quarters of those eligible electing not to breastfeed. Of the minority of women who did choose to breastfeed, more than half stopped within 1 week. The population of mothers on methadone and their infants has unique benefits to gain from breastfeeding due to the emotional, behavioural, and medical complications that often affect them. Breastfeeding has been shown to act as an analgesic for infants and is established to be beneficial for soothing agitated infants, potentially improving withdrawal symptoms in infants with neonatal abstinence syndrome. This vulnerable group of women would also seem to benefit from improved attachment to their infants (Wachman, Elisha). A strength of the retrospective review is that it can accumulate data for a large number of patients, as this one did. Patients in this review are unselected, therefore they are more likely to be standardized and more uniformly characterized. The study is very extensive and includes breastfeeding eligibility, initiation, continuation rates, and toxicology results. Ranges of different maternal psychiatric medications were taken into account. The limitations of the study include the lack of information as to why the rate of breastfeeding is so low among opioid dependent women. As this was a retrospective study, we are only able to see the effects of breastfeeding (or lack of) around the time of birth; there is no information as to how the infants or mothers have progressed from their hospital care. A major weakness is that these types of studies can generate a great deal of missed data. Missing data has the effect of reducing the effectiveness and power of the study.
Study 3
Effects of breast milk on the severity and outcome of neonatal abstinence syndrome by Abdel-Latif et al. (2006) assesses the effects of breast milk on the severity and outcome of neonatal abstinence syndrome. A retrospective cohort study was conducted of 190 drug dependent mother and infant pairs between 1998 and 2004 at the Royal Hospital for Women in New South Wales, Australia. After birth, infants were categorized according to the type of milk that was consumed on day 5 after. To monitor withdrawal, the Finnegan's scoring system was used. If the infant received two scores greater than 8, medication was administered to relieve this withdrawal. The average of Finnegan scores was significantly lower in the group receiving breast milk during the first week of life. Therefore, significantly fewer infants required withdrawal treatment in the breast milk group. The average time to experience any withdrawal symptoms occurred considerably later in the breast milk group. This was a multivariate analysis which observed for more than one outcome. It observed for the exposure to drugs of high-risk infants, multiple drug use, and prematurity. In this observation, the breast milk group was associated with lower need for neonatal abstinence syndrome treatment. It was concluded that breast milk intake is associated with reduced neonatal abstinence syndrome severity, delayed onset and decreased need for pharmacological treatment. This outcome is regardless of the gestational age of the infant and the type of drug they are exposed to (Abdel-Latif et al). This article was a quantitative non-experimental cohort study measured retrospectively. Strengths of this study include the ability to measure multiple outcomes, and many patients. It is relatively inexpensive, as the outcome and exposure have already occurred. Several measurements and outcomes were considered such as Finnegan's scoring system, chart pattern of illicit drug use, sporadic toxicology on the infant urine and meconium. Limitations include the investigator having no control over exposure or outcome assessment and relying on the record keeping of others. The comparability between intervention and control are difficult to achieve. As the previous study, potential missing data can reduce the power of the study.
The findings of these three sources are quite similar. They all came to the conclusion that skin-to-skin interaction with the newborn and mother provides a wide range of benefits. This includes reduced recovery time, decreased healthcare costs, and decreased pharmacological interventions. Two of the studies are retrospective where they look back at patients' records, and one of them is a randomized control trial. These articles are different where the first article by Cattaneo, A, et al. (1998) regards how breastfeeding is widely accepted and distributed in a wide range of populations. In the second article by Elisha Wachman (2010), the research explains how breastfeeding is not very common in new mothers with maternal pharmacological drug use.
Alternatives
When the mother of the infant is unable or chooses not to provide skin-to-skin care, the father could substitute this role. A study by Blomqvist et al (2012) concluded that the father's opportunity of being close to their infant increased their confidence and fulfillment of their parental role in the neonatal intensive care unit. Kangaroo care allowed them to experience some control and that they were doing something good for their infant. In comparison to skin-to-skin care with the mother, the father's role is equally as effective, but he is unable to provide the necessary breast milk. If neither parent were to be present within the hospital setting, necessary means such as incubation and formula feeding would take place. As noted in the previous study by Cattaneo (1998), infants would experience a greater benefit from kangaroo mother care compared to conventional methods of treatment such as incubation. When compared with health outcomes among formula-fed infants, the health advantages associated with breastfeeding include a lower risk of sudden infant death syndrome, gastroenteritis and diarrhea, acute otitis media, asthma, sever lower respiratory infections, obesity and other childhood disease and conditions (Salone, Lindsey. 2013).
Recommendations
My recommendations would be to include skin-to-skin/kangaroo interaction in all infant care, especially those with neonatal abstinence syndrome. Early skin-to-skin care can be easily incorporated into routine newborn care. This practice promotes optimal maternal-infant health outcomes and quality nursing care. Using the EBDM model, I would consider the clinical state, setting, and circumstances, the patient preferences and actions, research evidence, and health care resources. An assessment would be required to determine the use of alcohol or pharmacological drug use of new mothers. With this, the healthcare team would be able to determine whether or not the mother would be suitable for breastfeeding. Pharmacological treatments such as Methadone use is permitted with breastfeeding, as long as the dose is >80 mg/kg per day (Abdel-Latif et al. 2006). If the mother's preferences were to refrain from breastfeeding, I would still highly recommend skin-to-skin interaction with the infant. If the mother's clinical state were to be unstable, the father or another family member could substitute this role. This intervention can be performed in any setting - at the hospital or at home. There are many health care resources available for kangaroo care such as a Practical Guide from the World Health Organization (2003) and Breastfeeding Best Practice Guidelines, RNAO (2003). Most maternity units are well equipped with patient education pamphlets and provide patient education regarding the benefits of kangaroo care. Using evidence-based practice provides nurses with opportunities to implement practices that improve patient health and the birth experience (Dabrowski, 2007). The research evidence noted above clearly identifies how beneficial skin-to-skin care can be for the mother and baby. I would be able to bring this evidence with me into clinical practice and provide my recommendations to the patient. There should be a commitment to continue to educate the mother, her partner and family caregivers so that they are prepared to effectively care for the infant in the unit.
Conclusion
"Nurses have a professional duty to replace non evidence-based routines and practices during the birth experience with evidence-based practices" (Dabrowski, 2007). Evidence-based practices combine research evidence with clinical expertise and patient values to execute sound interventions that advance nursing practice, patient education and health outcomes (DiCenso, A., Guyatt, G., & Ciliska, D. 1997). Early skin-to-skin care is a straightforward example of an evidence-based practice intervention that, when integrated into the routine care of healthy newborns, creates a positive and beneficial experience for mothers and newborns. Kangaroo mother care is an efficient way to meet the infant's requirements for breastfeeding, warmth, stimulation, protection from infection, safety and love. (WHO, 2003). It reduces medical costs, further interventions, and pharmacological treatments. Nursing staff must be skilled in meeting the support needs of the breastfeeding mother of an infant with NAS. Care of infants with NAS in the NICU/SCNs is best provided in space that has been adapted to the use of kangaroo care (Dow, Kimberly et al. 2012).
