Introduction
Complications of preterm birth serve as one of the most important issues in neonatal medicine. The number of newborns dying each year is 2.7 million, which accounts for a total of 44% of children dying before they have chance to turn five worldwide (Chan, Labar, Wall, & Atun, 2016). A number of academic studies have demonstrated the efficacy and long-term health benefits of continuous skin-to-skin contact between a mother and her premature infant. This process is known as kangaroo mother care, or KMC. The KMC practice was established in California in 1978 (Mekonnen, Yehualashet, & Bayleyegn, 2019). It may include kangaroo position (close skin-to-skin contact), breastfeeding, and timely discharge with supportive care. These procedures are believed to be beneficial to the health of a newborn since they create an optimal environment for the child’ adaptation. According to Mekonnen et al. (2019), KMC plays “a significant role on infant survival, neurodevelopment, and the quality of mother-infant bonding” (para. 6). It is apparent that kangaroo care can reduce mortality and death in premature newborn if widely applied by medical professional.
Despite the efficacy of KMC, the adoption of the practice has been limited, which is why the global coverage remains low. The lack of a standardized definition of KMC makes its implementation difficult. The studies reveal that kangaroo mother care is a complex procedure, which consists of various components, including close contact, breastfeeding, early discharge, and various follow-ups (Chan et al., 2016). This paper is going to focus on the incorporation of skin-to-skin contact and its effects on a newborn’s stabilization and further development. Based on the critical assessment of four recent studies, the paper aims to conclude whether a practice change would be appropriate.
PICO(T) Question
Preterm infants serve as the population for the PICOT question. The intervention suggested in this paper is kangaroo mother care, which implies prolonged skin-to-skin contact between the mother and the baby. The main comparison is between KMC and a complete absence of kangaroo care. The expected outcome of the research is positive, based on the presented evidence. When the mother is involved in providing KMC to her preterm infant, it positively affects vital signs, behavioral development, pain occurrence, and overall health of the baby. Therefore, the research is going to be centered on the following PICO question: In preterm infants (P), how does KMC (I), compared to a lack of direct skin-to-skin contact (C), affect the infant’s stabilization, behavioral development, and overall health (O)?
Purpose Statement
The purpose of this critical appraisal paper is to review primary scholarly sources in order to assess the effectiveness of kangaroo mother care. This review aims to analyze the physical and psychological impact of KMC. The studies mentioned in the paper examine the physiological functions, sleep patterns and pain management mechanisms of premature infants introduced to kangaroo care. In particular, the main objectives of the paper include:
- To analyze the effects of KMC on premature newborns’ physiological functions.
- To identify the impact of skin-to-skin contact on pain relief among preterm infants.
- To determine the effectiveness of kangaroo care on maternal stress and mother-infant attachment.
- To evaluate the quality of presented research.
- To determine whether the suggested intervention would be appropriate, based on the evidence.
Major Concepts and Themes
The major theme of this paper is the implementation of kangaroo care into the established medical frameworks for preterm infants. In order to determine whether such an intervention would be appropriate, this review includes a “Critique of Research” section that discusses the strengths and weaknesses of chosen studies. The evidence is categorized according to the table by Polit & Beck (2012). Kangaroo mother care can be administered at three main levels:
- Mothers, fathers, and families
- Healthcare professionals
- Medical institutions (facilities)
The key concepts discussed in the review include skin-to-skin contact, preterm infants’ sleep patterns, neonatal pain, and maternal-infant attachment, which are discussed in detail in Bastani, Rajai, Farsi, & Als (2016), Campbell-Yeo et al. (2019), Cho et al. (2016), and Seo, Lee, & Ahn (2016). In addition, some of the aforementioned research articles contain arguments regarding maternal stress and premature neonates’ physiological functions.
Critique of Research
Describing the Studies
The aim of the study conducted by Bastani et al. (2016) was to compare the effects of in-arms-holding and kangaroo care on the sleep and wake patterns of preterm infants. The researchers opted for a randomized control trial (RCT), which assessed seventy-two stable infants with gestational ages of 32-37 weeks and their mothers. All of the participants were from a neonatal intensive care unit of an Iranian hospital based in Tehran. Seventy of them successfully completed all three phases of the study. The researchers concluded that the kangaroo care group experienced longer periods spent in deep sleep and quiet alert state during the intervention phase. However, there were no significant differences between the in-arms-holding and kangaroo care groups in terms of crying.
The purpose of the study conducted by Campbell-Yeo et al. (2019) was to examine and evaluate the sustained effect of kangaroo care on behavioral pain response. The RCT included 242 preterm infants under (or equal to) the gestational age of 36 6/7 weeks. Campbell-Yeo et al. (2019) concluded that maternal kangaroo care provided 15 minutes before heel lance can serve as an efficient pain-reducing intervention for preterm infants delivered between 27 and 36 weeks. These findings were consistent with the previous research of Campbell-Yeo at al., which “demonstrated that 30 minutes of maternal KC reduced crying, facial grimacing, and heart rate in preterm infants undergoing repeated heel lances when compared with no treatment” (2019, p. 2584). The study showed that non-pharmacologic interventions of maternal kangaroo care can be an efficient method of reducing pain in infants.
The objectives of the study conducted by Cho et al. (2016) were to identify the impact of kangaroo care (KC) on infants’ physiological functions, to explore maternal-infant attachment, and to assess the effectiveness of KC on maternal stress relief. The researchers used a quasi-experiment design with a nonequivalent control group and a pre/post testing. The researchers collected data from twenty preterm infants with corrected gestational ages of 33 weeks and older. Overall, the sample population included 40 infants, twenty of which were part of the control group, while others were in an experiment group. The intervention consisted of a total of 30 minutes of KC provided thrice a week (10 minutes per session). Cho et al. (2016) concluded that kangaroo care showed positive effects on stabilizing various physiological functions of infants, including respiration rate, oxygen saturation, and body weight. In addition, KC interventions resulted in the decrease of maternal stress as well as the increase of maternal-infant attachment.
Seo et al. (2016) aimed to determine the effects of kangaroo care on premature infants during neonatal heel sticks. Fifty-six infants in total participated in the study, with thirty of them being a part of the control group. The other 26 neonates were already undergoing kangaroo care. The researchers measured physiological responses of participants by heart rate and oxygen saturation. They used the Premature Infant Pain Profile (PIPP) in order to assess the behavioral and psychological responses of neonates to pain. The researchers concluded that no significant changes were observed in the levels of oxygen saturation between two groups. However, heart rates of the control group were significantly higher than those of the KC group after sampling. The results demonstrated that the PIPP scores were lower for the KC group during and after sampling. In addition, the duration of crying was significantly shorter for the group undergoing kangaroo care.
Comparing the Studies
Similarities
Bastani et al. (2016), Cho et al. (2016), and Seo et al. (2016) are all small in terms of sample population size compared to Campbell-Yeo et al. (2019). Despite that, all the studies presented in the paper are on the second level in evidence hierarchy, which makes them reliable. Additionally, they come to the same conclusions regarding the effectiveness of kangaroo care. Bastani et al. (2016) claim KMC positively affects neonates’ sleep patterns. Campbell-Yeo et al. (2019) show that KMC interventions are efficient in reducing pain in infants. Cho et al. (2016) conclude that the implementation of skin-to-skin contact results in the stabilization of infants’ physiological functions and the decrease in maternal stress levels. In addition, Seo et al. (2016) argue that preterm infants have better responses to pain if KMC is incorporated into the medical care framework. It is also important to note that Cho et al. (2016) and Seo et al. (2016) both compare KMC to the lack of skin-to-skin contact, while the other two studies present different alternatives to kangaroo care. This paper focuses on the lack of kangaroo care as the alternative to KMC interventions. Therefore, the findings presented by Cho et al. (2016) and Seo et al. (2016) are more applicable for this review.
Differences
As for the differences between the proposed studies, Campbell-Yeo et al. (2019) is the only relatively big one since it has managed to examine the effect of KMC on 242 infants. It was also one of the two research articles, which did not compare kangaroo care to the lack of skin-to-skin contact. Instead, Campbell-Yeo et al. focused on the outcomes pf pharmacologic vs. non-pharmacologic interventions. Bastani et al. (2016) was the other study, which compared KMC to in-arms holding, and not to the lack of KMC interventions. It is also important to note that while Seo et al. (2016) claim that KMC affects crying, Bastani et al. (2016) argue that kangaroo care interventions make no difference in relation to infants’ crying. Additionally, it is crucial to acknowledge that the article by Seo et al. (2016) does not include a section discussing the study’s limitations, while all the others do, which makes the research conducted by Seo and his colleagues seem less reliable. Finally, Cho et al. (2016) was the only study that focused on mothers, and not just infants, by assessing maternal stress and maternal-infant attachment.
Support for Innovation
It is apparent that Campbell-Yeo et al. (2019) and Cho et al. (2016) are the two studies that are the most reliable and applicable exclusively to this paper. Campbell-Yeo et al. (2019) have presented the most recent scientific findings since the study is only one year old. It also has the largest sample population, which makes it more reliable. Despite its quasi-experimental design, Cho et al. (2016) remains well-grounded. It is the only study, which examines maternal stress and attachment, and not just preterm infants’ physiological functions. Therefore, it is important to include the research presented by Cho et al. due to the diversity of the findings. Based on the evidence presented by these two groups of researchers, it is clear that kangaroo mother care can be an effective intervention for preterm infants and their mothers. The studies demonstrate the efficacy of KMC compared to the lack of it as well as to pharmacologic interventions.
Conclusion
Kangaroo care is an effective medical intervention that can benefit infants born prematurely and undergoing intensive care procedures. Based on the evidence presented in the aforementioned studies, KMC impacts neonates’ physiological functions, responses to pain, and sleep patterns in a positive way. The implementation of such interventions also reduces maternal stress and helps to increase the levels of attachment between mothers and their babies. A thorough critical analysis of studies regarding KMC demonstrated the importance of processing all the evidence before making conclusions. Campbell-Yeo et al. (2019) and Cho et al. (2016) helped to analyze the effects of kangaroo care interventions on premature newborns’ physiological functions, pain relief, as well as maternal stress. All of the studies helped to conclude that KMC positively affects the preterm infants’ stabilization, behavioral development, and overall health.
References
Bastani, F., Rajai, N., Farsi, Z., & Als, H. (2016). The effects of kangaroo care on the sleep and wake states of preterm infants. Journal of Nursing Research, 25(3), 231-239. Web.
Campbell-Yeo, M., Johnston, C. C., Benoit, B., Disher, T., Caddell, K., Vincer, M., … Inglis, D. (2019). Sustained efficacy of kangaroo care for repeated painful procedures over neonatal intensive care unit hospitalization: a single-blind randomized controlled trial. The Journal of the International Association of the Study of Pain, 160(11), 2580-2588. Web.
Chan, G. J., Labar, A. S., Wall, S., & Atun, R. (2016). Kangaroo mother care: a systematic review of barriers and enablers. Bulletin of the World Health Organization, 94(2), 130-141. Web.
Cho, E.-S., Kim, S.-J., Kwon, M. S., Cho, H., Kim, E. H., Jun, E. M., & Lee, S. (2016). The effects of kangaroo care in the neonatal intensive care unit on the physiological functions of preterm infants, maternal–infant attachment, and maternal stress. Journal of Pediatric Nursing, 31(4), 430-438. Web.
Mekonnen, A. G., Yehualashet, S. S. & Bayleyegn, A. D. (2019). The effects of kangaroo mother care on the time to breastfeeding initiation among preterm and LBW infants: a meta-analysis of published studies. International Breastfeeding Journal, 14(12). Web.
Seo, Y. S., Lee, J., & Ahn, H. Y. (2016). Effects of kangaroo care on neonatal pain in South Korea. Journal of Tropical Pediatrics, 62(3), 246-249. Web.
