HOME CME/CE INFORMATION PROGRAM DIRECTORS NEWSLETTER ARCHIVE EDIT PROFILE RECOMMEND TO A COLLEAGUE VOLUME 10 — ISSUE 6: TRANSCRIPT Featured Cases: New Perspectives On Kangaroo Care Our guest authors are Marilee C. Allen, MD, Professor of Pediatrics, and Maureen M. Gilmore, Assistant Professor of Pediatrics at Johns Hopkins University School of Medicine in Baltimore, Maryland. MEET THE AUTHORS Marilee C. Allen, MD Professor of Pediatrics Johns Hopkins University School of Medicine Baltimore, Maryland After participating in this activity, the participant will demonstrate the ability to: n Discuss the safety of kangaroo care, and barriers to its implementation in tertiary care NICUs. n Describe the impact of kangaroo care on the parents and NICU team. n Summarize the potential effects of kangaroo care on preterm neuromaturation. This discussion, offered as a downloadable audio file and companion transcript, covers the important topic of management of kangaroo care in the format of casestudy scenarios for the clinical practice. This program is a follow up to the Volume 10, Issue 5 eNeonatal Review newsletter— New Perspectives on Kangaroo Care. Unlabeled/Unapproved Uses Dr. Allen and Dr. Gilmore have indicated that there will be no references to unlabeled/unapproved uses of drugs or products. PROGRAM DIRECTORS Edward E. Lawson, MD Professor of Pediatrics Chief, Division of Department of Pediatrics Johns Hopkins Children's Center Baltimore, Maryland Maureen M. Gilmore, MD Assistant Professor of Pediatrics Director of Neonatology Johns Hopkins Bayview Medical Center Baltimore, Maryland Maureen M. Gilmore, MD Assistant Professor of Pediatrics Johns Hopkins University School of Medicine Baltimore, Maryland Faculty Disclosure Dr. Allen and Dr. Gilmore have indicated that they have no financial interests or relationships with any commercial entity whose products or services are relevant to the content of their presentation. Release Date April 30, 2015 Lawrence M. Nogee, MD Professor Department of Pediatrics – Neonatology Johns Hopkins University School of Medicine Baltimore, Maryland Expiration Date April 29, 2017 Mary Terhaar, DNSc, RN Associate Professor Director, DNP Program Johns Hopkins University School of Nursing Baltimore, Maryland Anthony Bilenki, MA, RRT Director Respiratory Care/ECMO Services The Johns Hopkins Hospital Baltimore, Maryland ACCREDITATION STATEMENTS Physicians: This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint providership of the Johns Hopkins University School of Medicine and the Institute for Johns Hopkins Nursing. The Johns Hopkins University School of Medicine is accredited by the ACCME to provide continuing medical education for physicians. 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PROGRAM BEGINS BELOW _ CME/CE INFORMATION STATEMENT OF NEED Nutrition n Physicians may not be aware of recent evidence-based recommendations on recognizing and treating GERD in neonates. n Current neonatal nutritional management practices may be enhanced to optimize and meet the specific needs of low birth weight preterm infants. n Current neonatal nutritional management practices may be enhanced to optimize and meet the specific needs of low birth weight preterm infants. n Clinicians who treat neonates are uncertain of optimal strategies for prevention and early recognition and treatment of necrotizing enterocolitis. Respiratory-Related Issues n Clinicians may be unfamiliar with some of the newest evidence-based approaches for treating neonatal persistent pulmonary hypertension. n Clinicians treating preterm infants may not be fully aware of the most recent developments in optimal management of bronchopulmonary dysplasia and respiratory distress syndrome. 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For CME certificates, please call (410) 502–9634. Johns Hopkins University School of Medicine Office of Continuing Medical Education Turner 20/720 Rutland Avenue Baltimore, Maryland 21205–2195 Reviewed and Approved by General Counsel, Johns Hopkins Medicine (4/1/03) Updated 4/09 HARDWARE & SOFTWARE REQUIREMENTS Pentium 800 processor or greater, Windows 98/NT/2000/XP/7 or Mac OS 9/X, Microsoft Internet Explorer 5.5 or later, 56K or better modem, Windows Media Player 9.0 or later, 128 MB of RAM, sound card and speakers, Adobe Acrobat Reader, storage, Internet connectivity, and minimum connection speed. Monitor settings: High color at 800 x 600 pixels. eNeonatal Review Podcast Transcript, Volume 10: Issue 6 eNEONATAL REVIEW PODCAST TRANSCRIPT MR. BOB BUSKER: Welcome to this eNeonatal Review podcast. Today’s program is a follow-up to our newsletter topic: New Perspectives on Kangaroo Care. With us today we have Dr. Marilee Allen, Professor of Pediatrics at the Johns Hopkins School of Medicine. Also joining us is eNeonatal Review program director Dr. Maureen Gilmore, Assistant Professor of Pediatrics at Johns Hopkins. eNeonatal Review is jointly presented by the Johns Hopkins University School of Medicine and the Institute for Johns Hopkins Nursing. This program is supported by educational grants from Abbott Nutrition, Ikaria, and Mead Johnson Nutrition. Learning objectives for this audio program include: n Discuss the safety of kangaroo care, and barriers to its implementation in tertiary care NICUs. n Describe the impact of kangaroo care on the parents and the NICU team. n Summarize the potential effects of kangaroo care on preterm neuromaturation. Dr. Allen and Dr. Gilmore have both indicated that they have no financial interests or relationships with a commercial entity whose products or services are relevant to the content of their presentation. They have also indicated that there will be no references to unlabeled or unapproved uses of drugs or products. MR. BUSKER: I’m Bob Busker, managing editor of eNeonatal Review. Dr. Allen, thank you for joining us today. DR. MARILEE ALLEN: Thank you for inviting me. This is an important topic. MR. BUSKER: And thank you as well, Dr. Gilmore. And welcome to the program. DR. MAUREEN GILMORE: Thank you, Bob, I’m happy to be with you today. MR. BUSKER: I think all of our listeners would agree that care in the NICU demands more technology than most other areas of the hospital. Now I don’t think it’s possible to imagine a lower-tech intervention than kangaroo mother care — and it may seem out of place in a high-tech NICU environment. But the evidence presented in the newsletter describes the benefits of kangaroo care, and talks about the need to translate those findings into practice. So let’s do some of that right now, by looking at some patient situations. Dr. Gilmore, start things off for us, if you would, please. DR. GILMORE: We had a 980 gm male who was delivered by C-section at 27 weeks gestation for preterm labor and fetal distress. His mom was a 35year-old gravida II, para 0-0-1-0 with a prior 20-week loss. During the mother’s current pregnancy, the baby was noted to have ascites and supraventricular tachycardia was diagnosed. This SVT and symptoms resolved with maternal digoxin treatment. At delivery the baby required intubation and ventilation, and his APGAR scores were 4, 5, and 7 at 1, 5, and 10 minutes. In the NICU he was extubated by about 12 hours of age to a nasal cannula, and he had no evidence of effusions, ascites, or SVT. His echocardiogram revealed just a small PDA and good biventricular function. MR. BUSKER: So what we have here is a baby who had been in trouble and now seems to be recovering fairly nicely. What was the family’s role in all this? DR. ALLEN: His mother visited him at about 14 hours after birth, and she needed encouragement to touch him. She returned the following day and cried when she held him for the first time. She began to produce some breast milk. Then he was started on some trophic gavage feedings. Fortunately, he remained physiologically stable, and the following week his parents were able to begin kangaroo care. His mother held him skin to skin between her breasts, with a blanket covering them both. MR. BUSKER: Dr. Allen, let me turn to you. Precautions to provide adequate warmth to this very preterm infant — what were the considerations there? DR. ALLEN: Kangaroo care originated in Colombia and other parts of South America. A mother would continuously hold her baby, meaning 24 hours a day, 7 days a week, skin to skin, upright between her breasts, with a wrap around both her and the baby. And this proved to be quite safe and efficacious in providing warmth and care to stable preterm infants eNeonatal Review Podcast Transcript, Volume 10: Issue 6 1 and allowed hospitals with limited resources to free up isolettes for sicker neonates. Studies have consistently demonstrated that kangaroo care not only provides adequate warmth to maintain stable temperatures of preterm infants, but some have shown that there is less variability in a preterm infant’s temperature than in an isolette. Unlike the continuous kangaroo care originally designed in Colombia, most studies of preterm infants in tertiary care NICUs have reported kangaroo care being provided by mothers and/or fathers for varying length of time, from 20 minutes to 13 ½ hours. The 2011 study by Blomqvist and Nygvist from Sweden reviewed in the newsletter is unique in that it reports on mothers’ experiences providing continuous 24/7 care to their preterm or ill neonates in a tertiary care NICU from admission to discharge, as opposed to intermittent care.1 MR. BUSKER: I want to ask you about the safety of kangaroo care. Things like apnea, infection, poor growth from increased energy requirements. What are the actual risks of kangaroo care? Dr. Gilmore? DR. GILMORE: Many studies, including the one by Carbasse, et al. which was reviewed in our newsletter, demonstrated good physiological stability with kangaroo care compared to preterm infants in isolettes, including, for example, the same or improved heart rate, improved respiration, improved oxygen saturation, temperature, etc.2 Dr. Allen? DR. ALLEN: A Cochrane review of 18 studies looked at kangaroo care in NICUs. In 16 of the studies the infants were stabilized, as in the case we were just talking about. Thirteen of the studies provided intermittent kangaroo care, and five provided continuous care. The studies found overall that there was a decreased mortality rate in the infants who got kangaroo care, decreased rates of infection or sepsis, decreased episodes of hypothermia, and a shorter length of stay. What was interesting was that they also found increased rates of breastfeeding and improved gains in the infant’s weight, length, and head circumference, which may well have led to a shorter length of stay. Other studies of cortisol levels in infants who received kangaroo care found that infants who got the kangaroo care had lower cortisol levels, which certainly suggests a reduced amount of stress in those infants. Another Cochrane study that looked at painful procedures in the NICU, for example, heel sticks, and found fewer signs of pain on pain scores and shorter duration of crying in neonates who received kangaroo care. So overall the evidence shows the safety of kangaroo care for preterm infants in a NICU and may even improve their level of stress and response to pain, which I think can be quite beneficial. MR. BUSKER: The criteria for selecting infants for kangaroo care in the NICU — what should clinicians be aware of? Dr. Allen? DR. ALLEN: I think this is fairly controversial. A number of reports in the literature on the safety and efficacy of kangaroo care in a NICU report a variety of criteria for which NICU infants were selected for kangaroo care in their unit. The Carbasse 2013 study, reviewed in the newsletter, is very interesting because they demonstrated the safety of kangaroo care for infants born at 24 to 33 weeks’ gestation, including intubated infants, as long as they required less than 50% oxygen and their ventilator rate was less than 50.2 They also couldn’t have any persistent pulmonary hypertension, respiratory events requiring intervention in the previous 12 hours, sepsis, or intraventricular hemorrhage. But of the infants studied, 18% of them were intubated, 30% were on CPAP, and as many as 11% of them still had umbilical venous catheters in. Do you have anything to add, Maureen? DR. GILMORE: Kangaroo care in extremely preterm infants and infants requiring respiratory support definitely requires skilled NICU staff who have experience with moving intubated preterm infants and those with continuous cardiorespiratory monitoring, and close staff observation of how the babies are doing. MR. BUSKER: Talk to us a little bit, if you would, about the barriers to implementing kangaroo care in a tertiary care unit. DR. ALLEN: Before kangaroo care can be implemented in a NICU, protocols must be established for selection criteria, transfer to and from eNeonatal Review Podcast Transcript, Volume 10: Issue 6 2 kangaroo care, nursing and respiratory care, monitoring, and procedures to follow if the infant is unstable. This is a totally new approach to caring for preterm infants in the NICU, and it requires the education and training of all NICU providers. The Hendricks-Munoz paper reviewed in the newsletter and the Mayers paper describing a nursing simulation training program for kangaroo care showed that the NICU nurses’ perception of, comfort with, and competency in providing kangaroo care benefited from those steps.3 Kangaroo care also requires a commitment from the family, which is the other major obstacle, because it takes a lot of their time and they need to be participating in their infant’s care. Nonetheless, I think kangaroo care should be viewed as an essential component of family-centered care of the NICU infant, and it should involve fathers as well as mothers. Ideally, implementing kangaroo care requires assessing a family’s strengths and challenges, discussing the benefits and risks of kangaroo care, helping parents understand the degree of commitment it entails, teaching them how to monitor their infant, educating them about how to recognize and respond to their infant’s cues, and partnering with them to provide a safe and nurturing environment for the infant. MR. BUSKER: The infant we started out discussing — He had a social smile, and he was very vocal and interactive, a delightful infant. On exam he did have some neuromotor abnormalities which are very common, and they included some asymmetries and some increased tone. We gave the parents some recommendations for positioning and working with him and felt he needed some ongoing physical therapy. During the clinic visit, though, his mother became quite tearful when describing how anxious she had been about his survival during the last six weeks of her pregnancy when she was taking the digoxin, and for his first several weeks in the NICU. She reported that when she had her daughter who died at 20 weeks’ gestation, she never had the opportunity to see or hold her daughter. For this second pregnancy of hers, for her son, his NICU nurses encouraged her and supported her and helped her hold him and participate in his care, and they helped her with the kangaroo care. She felt that they’d given her a gift of hope. Now that he’s home, she’s taken an extended leave of absence from work, and she remains committed to breastfeeding him. His father had also provided kangaroo care in the NICU, and in follow-up clinic he participated in answering a lot of the questions about his son’s feedings, behavior, and development, which I think is very telling and much more engaged than we usually see when it comes to fathers’ participation. Dr. Gilmore, what can you tell us about his follow-up? MR. BUSKER: Dr. Allen, let me ask you to continue to our follow-up clinic. We knew in the NICU he’d had some complications of prematurity including some mild RDS, a PDA, some gastroesophageal reflux, and anemia. Overall, though, he did very well, and he was discharged home at ten weeks and ad lib breastfeeding. His parents brought him back to the NICU follow-up clinic at four and a half months old with a corrected age of one and a quarter months for his prematurity. DR. ALLEN: Kangaroo care requires a substantial commitment of both time and effort of the parents. This was especially the case for the mothers of the preterm infants in the NICU in the paper from Sweden that was reviewed in the newsletter.1 These parents provided continuous kangaroo care from admission to discharge 24 hours a day, seven days a week. DR. GILMORE: We had this 27-week baby come back Dr. Allen, I understand that you were able to see this baby and his family in follow-up clinic. Can you tell us a little bit more about your interactions with them? DR. ALLEN: He was doing quite well. He had some reflux but had been feeding and growing very well. and tell us more about the effects of kangaroo care on the parents. Kangaroo care gives parents the opportunity for and empowers them to parent their preterm infant from the beginning instead of just passively watching as the NICU staff provides the care. Kangaroo care does a good job supporting a mother’s efforts and encourages determination to breastfeed by providing stimulation eNeonatal Review Podcast Transcript, Volume 10: Issue 6 3 for her breast milk production. Studies have demonstrated that kangaroo care increases the likelihood a mother will breastfeed and increases milk production duration of breastfeeding, even after discharge from the NICU. MR. BUSKER: And how has kangaroo care been shown to influence the parents’ subsequent care of their infant? DR. ALLEN: I think during their infant’s time in the NICU, kangaroo care reassures parents that their infant is growing and maturing, and they learn how to recognize and respond to their infant’s cues and needs. By the time of NICU discharge, parents know their infant very well, and they become more confident of their ability to care for their child once they take the child home. Studies of kangaroo care have demonstrated an increase in measures of parental bonding and involvement of fathers. Additional studies have demonstrated a decrease in measures of maternal depression and stress with kangaroo care of their preterm infant in a NICU. MR. BUSKER: Dr. Gilmore, you’re a director of a NICU. Tell us about the impact kangaroo care may have on the staff. DR. GILMORE: Parent education and initiation of kangaroo care with careful transfer of fragile infants and placement on the parents’ chests definitely requires substantial time investment from the NICU staff, especially the NICU nurses and respiratory therapists. It’s important that NICU staff continue to monitor the infant during kangaroo care and be available to the parents if they have any questions or concerns. As the infant grows and parents become accustomed to their role, they can assume some of the responsibilities of their infant’s care with consultation with the NICU staff as needed. And we’ve certainly seen, as parents have performed kangaroo care, they do become a little bit more comfortable with it over time. Parents usually are quite appreciative of the opportunity to provide kangaroo care and are grateful for the support they receive while their infant is in the NICU. This positive feedback from families can have a powerful influence on NICU staff and provide incentive to support the next infant’s family in kangaroo care. MR. BUSKER: Thank you, doctors, for bringing us that case and discussion. And we’ll return, with Drs. Allen and Gilmore, in just a moment. DR. MAUREEN GILMORE: Hello. I’m Maureen Gilmore, assistant professor of pediatrics and director of neonatology at Johns Hopkins Bayview Medical Center. I’m one of the program directors of eNeonatal Review. eNeonatal Review is a combination newsletter and podcast program delivered via email to subscribers. Newsletters are published every other month. Each issue reviews the current literature in areas of importance to neonatologists, respiratory therapists, neonatal nurses and nurse practitioners, and other health care practitioners whose work/practice includes treating neonates. Bimonthly podcasts are also available as downloadable transcripts, providing case-based scenarios to help bring that new clinical information into practice in the delivery room and at the bedside. Subscription to eNeonatal Review is provided without charge or prerequisite. Continuing education credit for each issue, and each podcast is provided by the Johns Hopkins University School of Medicine and the Institute for Johns Hopkins Nursing. For more information on this educational activity, to subscribe and receive eNeonatal Review without charge, and access backissues, please go to our website; www.eneonatalreview.org. Thank you. MR. BUSKER: And welcome back to our eNeonatal Review discussion: New Perspectives on Kangaroo Care. Our guests are Dr. Marilee Allen and Dr. Maureen Gilmore from the Johns Hopkins School of Medicine. And we’ve been discussing how some of the information presented in our last newsletter issue can be translated into practice in the NICU. So to continue, if you would please, Dr. Gilmore, describe another patient for us. DR. GILMORE: A 35-year-old mother was hospitalized at 30 weeks’ gestation for preeclampsia, and she eNeonatal Review Podcast Transcript, Volume 10: Issue 6 4 underwent an emergency C-section because of vaginal bleeding and possible abruption. The 1440 gm baby responded very well to routine care in the delivery room. In the NICU he developed some respiratory distress requiring some SiPAP support, but he was weaned off support by three days, and his parents were then able to hold him for the first time. He began some gavage feedings, advanced to full nipple and breast feedings, and having done well, was discharged home by five weeks. Unfortunately, kangaroo care was not routinely practiced at that time and was never offered to his parents. Dr. Allen, can you tell us more about the mother? DR. ALLEN: This mother was unable to visit her son for 24 hours because her treatment for preeclampsia. When she first saw him in the NICU, she cried seeing how scrawny and small he was, crying all alone in the isolette. His mother is a neurodevelopmental pediatrician and she worried that the NICU care that was saving his life was not providing the nurturing that she knew he also needed. She felt helpless and worried that his nurse knew more about him than she did. Maureen, do you want to talk about he did after discharge? DR. GILMORE: As you mentioned, his mother was a developmental pediatrician and she, of course, followed him very closely. He had some mild language delays, which improved by 15 months of age. By preschool he had good growth and fine motor skills and excellent visual perception with age-appropriate language skills. By age seven he had some difficulty learning to read, and his parents were concerned. At that point reading learning disability as well as some features of attention deficit disorder were diagnosed. Fortunately, he responded well to medications and tutoring. In high school, with follow-up evaluations, dyslexia was confirmed, and he benefited from accommodations in the classroom. He went on to graduate from high school and go to college. Marilee? DR. ALLEN: His astute mother, whom I know very well, in conversation with me wondered about whether kangaroo care, had it been available, might have influenced his development and if so how it might have. Clinically we recognize that formerly preterm adolescents, including those who do not develop major disabilities, still have higher rates of learning disability, attention deficit, executive dysfunction, and school and behavior problems than control infants who are born at term. MR. BUSKER: There seems to be a kind of general opinion that kangaroo care is likely to positively influence neurodevelopmental outcomes. Dr. Allen, what’s the evidence basis behind that? DR. ALLEN: One randomized trial of kangaroo care in preterm infants assessed them at 12 months, corrected for their degree of prematurity. The investigators found that infants who received kangaroo care had a 3.7 point higher cognitive score than controls, and there was some evidence of possible neuroprotection with kangaroo care in a subset determined to be at higher risk for neurodevelopmental disability at birth, based on a need for resuscitation at birth or neuromotor abnormalities when they were seen at six months. In 2014, as discussed in the newsletter, Feldman conducted a nonrandomized study of 73 preterm infants who were provided continuous kangaroo care for 14 consecutive days compared to 73 preterm control infants.4 They found that as these children were growing up, the group that received kangaroo care had significantly higher cognitive scores at 6, 12, and 24 months, but not at 5 and 10 years. However, they had higher scores on tests of executive function at 5 and 10 years. (For those of you who don’t know about executive function, executive function is the way that we organize ourselves, the way we determine what kind of task or problem we’re trying to solve, the strategy we’re going to use, assess how we are doing along the way, and make modifications so that we’re able to successfully accomplish it.) Another study, in a small study in Colombia in 1994 of adolescents who were born preterm, used transcranial magnetic stimulation to assess cerebral motor function and found that these adolescents who had received kangaroo care had faster conduction times and inhibition. eNeonatal Review Podcast Transcript, Volume 10: Issue 6 5 A review of the literature, however, concludes that there’s insufficient evidence to determine the effect of kangaroo care on neurodevelopmental outcome and preterm survivors with any degree of certainty. Clearly more research is needed. DR. GILMORE: Marilee, how can kangaroo care influence preterm neuromaturation while the infant is still in the NICU? DR. ALLEN: Let’s first talk about how current standard neonatal intensive care for preterm infants differs from the intrauterine environment. There’s immediate and prolonged separation from the mother, bombardment of the preterm nervous system with meaningless sensory stimuli, limited opportunities for human touch, multiple painful stimuli with no or limited analgesia, restricted kinesthetic and olfactory stimulation, and interactions that are not related at all to the infant’s cues or state of alertness. Kangaroo care provides physiologic stability for one thing, allowing for undisturbed neuromaturation, and it provides continuous skin contact and exposure to the mother, a parent’s smell and taste; and the parental movement while providing kangaroo care provides some gentle kinesthetic stimulation. All of these are good experiences for a developing nervous system. Kangaroo care can also shield the infant from extraneous light and noise and provide appropriate cue-based exposure to the parent’s face and speech. If the baby’s sleeping, of course, the exposure would be minimized. But if the baby is awake and in a quiet, alert state, that’s the perfect time for the parent to start talking to the infant. Kangaroo care has also been shown to be an effective analgesic for painful stimuli, reducing both the intensity of the infant’s pain response and time to recovery. Probably more important, kangaroo care gives parents an opportunity to learn to recognize and appropriately respond to their infant’s cues. MR. BUSKER: Dr. Allen, one final question on this patient. What are the measurable physiological effects of kangaroo care on neuromaturation? DR. ALLEN: Several studies have shown that infants who receive kangaroo care had more quiet sleep and longer sleep cycles. As in the Feldman trial reviewed in the newsletter, there are more organized sleep/wake cycles than in control preterm infants.4 Some studies have demonstrated lower cortisol levels, lower stress reactivity, and higher oxytocin levels in preterm infants who receive kangaroo care. In the 2014 study by Welch, et al reviewed in the newsletter5, they obtained EEGs during sleep at 35 and 40 weeks postmenstrual age in preterm infants who had received their family nurture intervention which included kangaroo care. They found increased frontal brain activity with neuromaturation, which was not found in the control preterm infants. Other studies have showed that increased brain activity, especially in the frontal region, has been associated with lower risk of attention deficit, executive dysfunction, and mental health problems, which I find very intriguing. MR. BUSKER: Doctors, thank you both for today’s cases and discussion. I’d like to go to a more general question now— and that’s to ask you what areas of kangaroo care do you think most require further research? Dr. Gilmore? DR. GILMORE: It seems that safety as well as the physiological stability of infants with kangaroo care have been very well supported and defined in the literature. In addition, I think the efficacy of kangaroo care in pain control has also been pretty nicely documented. The remaining question, then, is neuromaturation. Literature reviews conclude that there’s still at this point insufficient evidence to determine the effect of kangaroo care on preterm neuromaturation or on neurodevelopmental outcome in preterm survivors. Marilee, other thoughts? DR. ALLEN: Intriguing data support our current understanding of preterm neuromaturation and recovery for preterm brain injury, suggesting a beneficial and/or neuroprotective effect of kangaroo care. In light of the persistent neurodevelopmental difficulties that children born preterm and their families face, I think the data are compelling enough to support ongoing investigation of the effect of kangaroo care on preterm development. eNeonatal Review Podcast Transcript, Volume 10: Issue 6 6 MR. BUSKER: Thank you for those thoughts, doctors. Let’s wrap things up now by reviewing today’s discussion in light of our learning objectives. So to begin: the safety of kangaroo care and the barriers to its implementation in tertiary care NICUs. Dr. Gilmore? DR. ALLEN: Thank you for this opportunity. It’s been a pleasure to talk about such an important topic. important points. Kangaroo care has been shown to be safe and efficacious for preterm infants born at 24 to 33 weeks’ gestation. Kangaroo care has also been associated in numerous studies with physiologic stability. We’ve touched on the fact that NICU staff as well as providers lack some familiarity with the benefits of kangaroo care, but this can be overcome by an education program and some simulation training. please take the post-test at www.eneonatalreview.org/test. DR. GILMORE: We’ve touched on a couple of MR. BUSKER: Dr. Allen, our second learning objective: the impact of kangaroo care on the parents and the NICU staff. DR. ALLEN: Kangaroo care may have direct effects for parents, including decreased stress and decreased maternal anxiety and depression. Kangaroo care strengthens maternal-infant bonding, facilitates breastfeeding, and can help parents feel more competent when caring for their infant. For the NICU staff, a comprehensive educational program, coupled with simulations, was very effective in improving staff perception, comfort, and competency in kangaroo care. MR. BUSKER: And finally: the effects of kangaroo care on preterm neuromaturation. Dr. Allen? DR. ALLEN: Kangaroo care certainly provides physiologic stability and can influence preterm neuromaturation while the infant’s still in the NICU, as in the associated increased frontal lobe activity during sleep which was demonstrated in the Welch study.5 We also discussed studies that provide examples of how kangaroo care may have an impact on longer term neuromaturation after a NICU discharge and into early childhood, as in the Feldman study.4 Clearly, more work is needed in this area. MR. BUSKER: From the Johns Hopkins School of Medicine, Dr. Marilee Allen, Dr. Maureen Gilmore, thank you for being part of this eNeonatal review podcast. DR. GILMORE: Thanks, Bob, for inviting me to participate in today’s podcast on kangaroo care. I really appreciate the opportunity. MR. BUSKER: To receive CME credit for this activity, This podcast is presented in conjunction with the eNeonatal Review Newsletter, a peer-reviewed literature review certified for CME/CE credit, emailed monthly to clinicians treating patients in the NICU. This activity has been developed for neonatologists, respiratory therapists, neonatal nurses, nurse practitioners, and other members of the NICU team. This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education, through the joint sponsorship of the Johns Hopkins University School of Medicine and the Institute for Johns Hopkins Nursing. The Johns Hopkins University School of Medicine is accredited by the ACCME to provide continuing medical education for physicians. The Johns Hopkins University School of Medicine designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit(s).™ Physicians should claim only the credit commensurate with the extent of their participation in this activity. The Institute for Johns Hopkins Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. For nurses, this 0.5 contact hour Educational Activity is provided by the Institute for Johns Hopkins Nursing. Each podcast carries a maximum of 0.5 contact hour. This educational resource is provided without charge, but registration is required. To register to receive eNeonatal Review via email, please go to our website: www.eneonatalreview.org. eNeonatal Review Podcast Transcript, Volume 10: Issue 6 7 The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of the names of the Johns Hopkins University School of Medicine and the Institute for Johns Hopkins Nursing implies review of educational format, design, and approach. Please review the complete prescribing information for specific drugs, combinations of drugs, or use of medical equipment, including indication, contraindications, warnings, and adverse effects, before administering therapy to patients. eNeonatal Review is supported by educational grants from Abbott Nutrition, Ikaria, and Mead Johnson Nutrition. This program is copyright with all rights reserved by the Johns Hopkins University School of Medicine and the Institute for Johns Hopkins Nursing. eNeonatal Review Podcast Transcript, Volume 10: Issue 6 8 REFERENCES 1. Blomquist YT, Nygvist KH. Swedish mothers' experience of continuous Kangaroo Mother Care. J Clin Nurs. 2011 May;20(9-10):1472-1480. 2. Carbasse A, Kracher S, Hausser et al. Safety and effectiveness of skin-to-skin contact in the NICU to support neurodevelopment in vulnerable preterm infants. J Perinat Neonatal Nurs. 2013;27(3):255-262. 3. Hendricks-Munoz KD, Mayers RM. A neonatal nurse training program in kangaroo mother care (KMC) decreases barriers to KMC utilization in the NICU. Am J Perinatol. 2014;31(11):987-992. 4. Feldman R, Rosenthal Z, Eidelman AI. Maternal-preterm skin-to-skin contact enhances child physiologic organization and cognitive control across the first 10 years of life. Biol Psychiatry. 2014;75(1):56-64. 5. Welch MG, Myers MM, Grieve PG, et al; FNI Trial Group. Electroencephalographic activity of preterm infants is increased by Family Nurture Intervention; a randomized controlled trial in the NICU. Clin Neurophysiol. 2014 Apr;125(4):675-684 eNeonatal Review Podcast Transcript, Volume 10: Issue 6 9
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